REFRESHER PRE BOARD EXAMINATION

Nursing Practice II: Care of Healthy and At Risk Mother and Child
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 invalid 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 I” on the box provided.
Situation: The birth process affects the holistic aspects b. 8 and 10
of the mother, to include physiologic changes to both c. 10 and 12
the mother and the fetus. Nursing students are now d. 16 and 20
assigned at the OB Admitting Section of the National 7. The mother asks about gestational diabetes, as she has
Hospital. familial history and was worried about her pregnancy.
1. A nurse is performing an assessment of a pregnant Which statement by the client indicates a further need for
woman who is at 28 weeks of gestation. The nurse education?
measures the fundal height in centimeters and expects the a. “I need to be in a diabetic diet”
finding to be which of the following? The student nurse b. “I will perform glucose monitoring at home”
correctly identifies: c. “I need to avoid exercise because of the negative
a. 22 cm c. 36 cm effects of insulin production”
b. 30 cm d. 40 cm d. “I need to be aware of any infections and report
2. A nursing student is preparing a class on the process of signs of infection immediately”
fetal circulation. The instructor asks the student 8. History revealed that there is a history of twins in the
specifically to describe the process through the umbilical family and the client was asking about the possibility of
cord. Which of the following statements from the student having twins as well. The nurse replies:
is correct? A. Monozygotic twins result from fertilization of two ova
a. “The one artery caries freshly oxygenated blood and by different sperm.
nutrient-rich blood back from the placental to the B. Monozygotic twins occur by chance regardless
fetus” of race or heredity.
b. “The two arteries carry freshly oxygenated C. Dizygotic twins are usually of the same sex.
blood and nutrient-rich blood back from the D. Dizygotic twins occur more often in primigravidthan
placental to the fetus.” in multigravid clients.
c. “The two arteries in the umbilical cord carry blood 9. Sheila, the client’s mother, was worried that her daughter
that is high in carbon dioxide and other waste will have an enormous amount of blood loss during
products away from the fetus to the placenta.” delivery. As a nurse, the best response would be:
3. Which of the following are not presumptive sign/ symptom a. The maximum blood loss considered within
of pregnancy? normal limits is 500 mL.”
a. Amenorrhea c. Softening of the b. “The minimum blood loss considered within normal
uterus limits is 1,000 mL.”
b. Urinary changes d. Nausea/ vomiting c. “Blood loss during a delivery is rarely estimated
4. Of the following probable signs of pregnancy, which unless there is a hemorrhage.”
describes the bluish discoloration of the vagina? d. “It would be very unusual if you lost more than 100
a. Chadwick’s sign c. Goodel’s sign mL of blood during the delivery.”
b. Hegar’s sign d. Ballotement 10. During the next visit, the client attended a childbirth
5. A nurse is reviewing the record of a client who has just preparation class and tells the nurse that her lower back
been told that a pregnancy test is positive. The physician has been aching. Which of the following exercises are
has documented the presence of Goodel’s sigm. The staff appropriate for the client?
nurse asks the student nurse and she states that this is: a. Pelvic rocking c. Tailor sitting
a. A softening of the cervix b. Deep breathing d. Squatting
b. The presence of fetal movement 11. Syphilis is a chronic disease cause by Treponema
c. The presence of HCG in the urine palladium. Which of the following is not true about syphilis?
d. A soft blowing sound that corresponds to the a. Transmission is by physical contact with
maternal pulse during auscultation of the uterus. syphilitic lesions, which are usually found on
Situation: A G1P0 mother went to the health center for the skin, mucous membranes of the mouth,
a check-up. You are the nurse assigned. or genitals.
6. The mother asks the nurse when she will be able to begin b. The infection may not cause abortion
feeling the fetal movements. You respond by telling the or premature labor.
mother that fetal movements will be noted between which c. It may be passed to the fetus on the fourth
of the following weeks of gestation? month of pregnancy as congenital syphilis.
a. 6 and 8

TOP RANK REVIEW ACADEMY, INC. Page 1 | 8

 d. A serum test (Veneral Disease Research a. The client is a 36- year old primigravida
Laboratory or rapid plasma reagin) for b. The client has a history of cardiac disease
syphilis on the first prenatal visit, and c. The client’s haemoglobin level is 13.5 g/dL
repeated on the 36th week of gestation. d. The client is a 20year old primigravida of average
12. Gonorrhea is an infection cause by Neisseria gonorrhoeae weight and height.
that causes inflammation of mucous membrances of the 19. A nurse in a labor room is monitoring a client with
genital and urinary tracts. Which of the following is true? dysfunctional labor for signs of fetal or maternal
a. Transmission of the organism is by airborne. compromise. Which of the following assessment findings
b. Infection is not transmissible to a newborn. would alert the nurse to a compromise?
c. It may cause Opthalmianeonatorum. a. Maternal fatigue
d. It is usually symptomatic, and vaginal b. Coordinated uterine contractions
discharge is common. c. Progressive changes in the cervix
13. A clinic nurse is performing a psychosocial assessment of d. Persistent nonreassuringfetal heart rate
Alice. Which assessment finding indicates to the nurse 20. A client in labor is transported to the delivery room and
that the client is at high risk for contracting human prepared for ta caesarean delivery. After the client is
immunodeficiency virus? transferred to the delivery room table, a nurse places her
a. A client who has a history of in:
intravenous drug use. a. Supine position with a wedge under the right
b. A client who has a significant other who is hip
heterosexual b. Trendelenburg’s position with the legs in stirrups.
c. A client who has a history of sexually c. Prone position with the legs separated and elevated
transmitted diseases. d. Semi-Fowler’s position with a pillow under the knees.
d. A client who has had 1 sexual partner for the
past10 years. SITUATION: Grounded theory is a general inductive
14. When Alice was in her third trimester, she was admitted to method that is not inextricably linked to a particular
the hospital with a diagnosis of sever preeclampsia. A theoretical perspective or type of data. Grounded theory
researchers seek to understand the actions in a
nurse monitors for complications associated with the
substantive area from the perspectives of those
diagnosis and assesses the client for: involved.
a. Enlargement of the breasts 21. The nurse researcher comprehends that people who
b. Complaints of feeling hot when the room is pioneered studies in grounded theory includes the
cool. following apart from?
c. Periods of fetal movement followed by quiet a. Glaser & Strauss c. Corbin&
periods. Tanner
b. Strauss & Corbin d. None of the
d. Evidence of bleeding, such as in the
above
gums, bruises, petechiae, and purpura. 22. Coding in Glaserian grounded theory approach is used to
15. Alice gave birth to a stillborn infant. After the delivery, the conceptualize data into patterns. The nurse-researcher
family remained together, holding and touching the infant. incorrectly identifies conceptualization of the substance of
Which statement by the nurse would further assist the the topic under study as:
family in their assist the family in their initial period of a. Substantive codes c. Selective codes
b. Open codes d. Theoretical codes
grief?
23. In-vivo codes are directly derived from the language of the
a. “Anong pwede kong gawin para saiyo?” substantive area. The nurse-researcher correctly identifies
b. “Ngayon may anghel ka na sa langit” these codes as:
c. “Huwag kang mag-alala, wala tayong hindi a. Level I c. Level III
nagawa” b. Level II d. Level IV
d. “Gagawa tayo ng paraan na mapauwi ka ng 24. In grounded theory approach, data analysis employs:
maaga para di mo na maalala ang mga a. Domain analysis
b. Constant comparative analysis
pinagdaanan mo dito”
c. Componential analysis
16. Which of the following is a proper description for Placenta d. Taxonomic analysis
Accreta? 25. The six (6) C’s in families of theoretical codes for
a. Premature separation of the placenta of the uterine grounded theory analysis developed by Glaser (1978)
wall after the twentieth week of gestation and before excludes:
the fetus is delivered a. Contingencies c. Continuum
b. The placenta penetrates the uterine muscle itself b. Covariances d. Consequences
26. The nurse is teaching a postpartum client about
c. An abnormally adherent placenta
breast-feeding. Which of the following instructions should
d. Placenta goes all the way through the uterus.
the nurse include?
17. A nurse in the labor room is preparing to care for a client
a. Prenatal vitamins should be discontinued.
with hypertonic uterine contractions. The nurse is told that
b. The diet should include additional fruits.
the client is experiencing uncoordinated contractions that
c. Organic, hypoallergenic soap should be used to
are erratic in their frequency, duration, and intensity. The
cleanse the breasts.
priority nursing intervention in caring for the client is to:
d. Galactagogues should be avoided.
a. Provide pain relief measures
27. A nurse is planning to care for a post-partum client who
b. Prepare the client for an amniotomy
had a vaginal delivery 2 hours ago. The client had a 4cm
c. Promote ambulation every 30 minutes
midline episiotomy and has several haemorrhoids. What is
d. Monitor the oxytocin infusion closely.
the priority nursing diagnosis for this client?
18. Jenny, a nurse, is performing an initial assessment on a
a. Acute pain
client who has just been told that a pregnancy test is
b. Disturbed body image
positive. Which assessment finding would indicate that the
c. Impaired urinary elimination
client is at risk for preterm labor?
d. Risk for imbalanced fluid volume.
TOP RANK REVIEW ACADEMY, INC. Page 2 | 8
28. A nurse is caring for four 1-day postpartum clients. Which d. Women who are able to have at least 3 hours of
client has an abnormal finding that would require further continuous sleep every day at almost the same time
intervention? can use BBT.
a. The client with mild afterpains rated 4/10 33. The Ovulation Method or “OM” entails having to observe
b. The client with a pulse rate of 70 beats per minute the changes in color, consistency and amount of
c. The client with colostrum discharge from both breasts discharge. Which of the following is not true?
d. The client with lochia that is red and has a foul a. During infertile days, the uterine cervix secretes a
smelling color. discharge which is thick and scanty in which sperm
29. Robi, a nurse, is providing postpartum instructions to a survival is poor.
client who will be breast-feeding her newborn. Which of b. On fertile days, discharge is thin and copious. This
the following determines that the client understood the type of discharge is conducive for sperm penetration
instructions? Select all that apply. and survival and subsequent fertilization.
1. “magsusuot ako ng bra na may suporta” c. During the woman’s fertile period, she feels dry
2. “Nakakasama ang pag-inom ng alak para sa and sees stretchy and clear discharge.
aking gatas-ina” d. During the woman’s fertile period, the discharge
3. “Ang kape ay maaaring makakapagpababa ng nourishes and provides a channel for sperm to reach
aking gatas-ina” the egg.
4. “Sisimulan ko ang pag-inom ng estrogen pills pag R: OM is also called CMM. During the fertile period, she feels
karating sa amingbahay” wet and sees slippery, stretchy, watery and clear mucus.
5. “Alam ko na kung ang aking suso ay panandaliang 34. CycleBeads™ represents the woman’s menstrual cycle.
lumaki, ihihinto ko ang pagpapasuso” Each bead represents a day of her cycle. Which of the
6. “Iinom ako ng maraming tubig upang maparami following is true?
ang aking gatas-ina” a. The RED bead marks the first day of menstrual
period.
A. 1, 6, 5, 3 b. The WHTE beads represent the days when the
B. 1, 2, 3, 6 woman can have intercourse and not become
C. 2, 3, 4, 5 pregnant.
D. 3, 4, 5, 6 c. The BROWN beads are the days when a woman can
become pregnant.
30. A prolapsed umbilical cord is when the umbilical cord is d. The CHOCOLATE BROWN bead helps you know if
displaced between the presenting part and the amnion or your cycle is less than 24 days long.
protruding through the cervix, causing compression of the 35. Nurse Josh stated that the Lactational Amenorrhea
cord and compromising fetal circulation. Which of the Method (LAM) was not applicable for Rose. The LAM
following assessment findings are not indicative of a method:
prolapsed cord? a. Is for non- breastfeeding mothers
a. The client has a feeling that something is coming b. Is for mothers whose menstruation has returned (this
through the vagina. does not include the spotting that occurs 56 days post
b. Umbilical cord is visible or palpable partum)
c. Sweating, cool and damp skin c. Is for mothers whose infant is more than 24 weeks
d. Fetal heart monitor shows variable decelerations or old
bradycardia after rupture of the membranes. d. Is considered as a temporary, short-term
Situation: Joshua is a public health nurse assigned in method.
the family planning clinic. Rose, a 19 year old client 36. Which of the following is a proper description for Placenta
reported that she has been sexually active for one year Accreta?
and is asking about family planning methods. a. Premature separation of the placenta of the uterine
31. Nurse Joshua talks to the client regarding Natural Family wall after the twentieth week of gestation and before
Planning Methods which are based on scientific facts on the fetus is delivered
fertility. Which of the following are not natural methods of b. The placenta penetrates the uterine muscle itself
FP? c. An abnormally adherent placenta
a. Sympto-Hormonal Method (SMH) d. Placenta goes all the way through the uterus.
b. Sympto-Thermal Method (STM) 37. A nurse in the labor room is preparing to care for a client
c. Cervical Mucus Method (CMM) with hypertonic uterine contractions. The nurse is told that
d. Modified Pomeroy Method (MPM) the client is experiencing uncoordinated contractions that
32. BBT is another natural FP method. Which of the following are erratic in their frequency, duration, and intensity. The
is not true about this method? priority nursing intervention in caring for the client is to:
a. The basal body temperature of a woman is a. Provide pain relief measures
higher before ovulation, until it decreases to a b. Prepare the client for an amniotomy
lower level beginning around the time of c. Promote ambulation every 30 minutes
ovulation. d. Monitor the oxytocin infusion closely.
b. After her ovulation, her BBT typically rises slightly and 38. Jenny, a nurse, is performing an initial assessment on a
stays in a slightly higher range until her next period client who has just been told that a pregnancy test is
begins. This slight increase in BBT from ovulation until positive. Which assessment finding would indicate that the
menstruation is a sign that she ovulated during this client is at risk for preterm labor?
cycle. a. The client is a 36- year old primigravida
c. The BBT of a woman is lower before her ovulation, b. The client has a history of cardiac disease
until it rises to a higher level beginning around the c. The client’s haemoglobin level is 13.5 g/dL
time of ovulation. d. The client is a 20year old primigravida of average
weight and height.

TOP RANK REVIEW ACADEMY, INC. Page 3 | 8

 39. A nurse in a labor room is monitoring a client with a. Colaizzi’s c. Giorgi’s
dysfunctional labor for signs of fetal or maternal b. Van Kaam’s d. Van Manen’s
compromise. Which of the following assessment findings
Situation: The goal of the Integrated Management of
would alert the nurse to a compromise?
Childhood Illnesses is to significantly reduce global
a. Maternal fatigue
mortality and morbidity associated with major causes
b. Coordinated uterine contractions
of diseases in children, and to contribute to healthy
c. Progressive changes in the cervix
growth and development of children.
d. Persistent nonreassuringfetal heart rate
40. A client in labor is transported to the delivery room and
46. This program is the campaign for all practitioners and
prepared for ta caesarean delivery. After the client is
health facilities to adopt and embrace the safe and quality
transferred to the delivery room table, a nurse places her
care of Essential Intrapartum and Neonatal Care (EINC)
in:
for our birthing mothers and their newborns.
a. Supine position with a wedge under the right
a. Family Planning c. UnangYakap
hip
b. MNCHN d. MDG 4 & 5
b. Trendelenburg’s position with the legs in stirrups.
47. The Department of Health issues this Administrative Order
c. Prone position with the legs separated and elevated
to guide health workers in revitalizing and sustaining
d. Semi-Fowler’s position with a pillow under the knees.
mother-baby friendly hospitals, so as to promote and
support breast-feeding.
SITUATION: Schumacher, L. (2010) conducted a
a. AO 2007-0025
phenomenological study entitled “The caregiver’s
journey: a phenomenological study of the lived b. AO 2007-0026
experience of leisure for caregivers in the sandwich c. AO 2007- 0027
generation who care for a parent with dementia.” She d. d. AO 2007- 0028
focused her study on the subjective burden of care 48. The Essential Intrapartum Neonatal Care Evidence-based
giving and lived bereavement of mid-life people who standard practices for safe and quality care of birthing
were simultaneously caring for a parent with Alzheimer’s
mothers and their newborns, within__ hours of
Disease and Related Disorders (ADRD) and a dependent
child to fully capture the essence of the experience. intrapartum period (labor and delivery)and a week of life
for the newborn.
41. Phenomenologists believe that lived experience gives a. 12
meaning to each person’s perception of a particular b. 24
phenomenon. A nurse-researcher has an accurate c. 36
understanding of phenomenological inquiry if she states d. 48
that the aspects of lived experience that are of interest to
49. Which of the following are not included in the EINC
phenomenologists are the following but:
a. Spatiality c. Temporality practices during the intrapartum period?
b. Corporeality d. Rationality a. Spontaneous pushing in a semi-upright position
b. Physical contact between mother and the
42. The nurse researcher misunderstood the newborn
phenomenological process if she stated that the main c. Continuous maternal support by a companion of
method of data collection in phenomenological studies are choice
the following but?
d. Non-drug pain relief
a. Participant observation
b. Use of close-ended interview questions 50. A nurse was performing the EINC practices for newborn
c. In-depth interview sessions care, which are time-bound interventions at the time of
d. Let the patient describe the lived experience through birth. Which of the following practices is done third?
essay a. UnangYakap
43. Bracketing is a process of identifying and holding in b. Properly-timed cord clamping and cutting
abeyance preconceived beliefs and opinions about the
c. Early skin-to-skin contact between mother and
phenomenon under study. It’s a technique to minimize
bias in Husserlian phenomenology. Ahern (1999) provided the newborn
tips to help qualitative researchers with bracketing d. Immediate and thorough drying of the newborn
through notes in a reflexive journal. The nurse researcher
may do the following excluding: Situation: You are the nurse assigned in the nursery
a. Identify interests that the research unit and your patients are of various ages.
participants may take for granted 51. Assessment an infant, the nurse knows that a pincer grasp
b. Recognize gatekeepers’ interests and make note of normally appear
the degree to which they are favorably or A. At the same time as the palmar grasp
unfavorably disposed toward the study B. Between 9 & 12 month of age
c. Reflect on and profit from methodologic problems C. Between 5 & 7 month of age
that occur during the study D. Along with the ability to "rake" objects toward themselves
d. Consider addressing biases in data collection or
analysis by interviewing the participant the second 52. In a child development, the period of negativism begins
time or reanalyzing the transcript in question when the child
44. According to Gadamer (1976), the interpretive A. Can manipulate his or her parents
phenomenology process must start from the whole of a B. Copies negative behavior of sibling.
text in terms of its parts and the parts in terms of the C. Is struggling between dependence and
whole. The nurse-researcher correctly identifies this independence
process as: D. Is learning manual skills
a. Circular bracketing c. Cyclical deduction
b. Intuiting d. Hermeneutic circle 53. The nurse is caring for a hospitalized toddler who was
45. The nurse-researcher now performs analysis of toilet trained home. He wets his pants. The best response to
phenomenological data. She chooses a method which this situation is to say
requires inter-subjective agreement to be reached with A. "It’s okay, try not to wet your pants next time”
other expert judges. She correctly identifies the method B. "That's okay. Now let’s get you cleaned up”
as:
TOP RANK REVIEW ACADEMY, INC. Page 4 | 8
C. "I know you understand how to use the toilet; what 4. Maternal and Child Health and Nutrition
happened?" 5. Prevention of Infertility and sexual Dysfunction
D. "Your mom told me you don't wet anymore; what's wrong?"
A. All except 5 C. 2,3,4,5
54. Which of the following behavior would a normal 18 months B. 1,3,4,5 D. 1,2,4,5
old be likely to exhibit during the first few hours of
hospitalization? Situation: A pregnancy can be considered a high-risk
A. Crying loudly when parents leave pregnancy for a variety of reasons. It is one in which
B. Readily accepting the nurse caring for him some condition puts the mother, the developing fetus,
C. Showing considerable interest in new toy or both at higher-than-normal risk for complications
D. Sitting quietly in the comer of the cab, showing little or no during or after the pregnancy and birth.
interest in his surrounding 63. Which of the following is the most likely effect on the fetus
if the woman is severely anemic during pregnancy?
55. Jason answers every question of his mother by saying A. Large for gestational age (LGA) fetus
“No!” How can she minimize this? B. Hemorrhage
A. Tell Jayson she doesn’t want him to say no anymore C. Small for gestational age (SGA) baby
B. Answer all Jayson’s question by saying “No” D. Erythroblastosis
C. Reduce number of questions she asks Jason.
D. Explain hen is not using good communication skills. 64. Upon assessment the nurse found the following: fundus at
2 fingerbreadths above the umbilicus, last menstrual period
Situation: Nurse Rose is the school nurse in Jose Reyes (LMP) 5 months ago, fetal heart beat (FHB) not appreciated.
Elementary school. Her responsibility is to attend to the Which of the following is the most possible diagnosis of this
health needs of the students particularly nutrition. condition?
56. Kwashiorkor is a condition usually seen among pre- school A. Hydatidiform mole C. Pelvic inflammatory disease
children. This is characterized by which of the following signs? B. Missed abortion D. Ectopic pregnancy
A. retarded growth and hairs C. edema
B. loss of appetite D. all these signs 65. When a pregnant woman goes into a convulsive seizure,
the MOST immediate action of the nurse to ensure safety of
57. Vitamin A deficiency will lead to which of the following the patient is:
conditions? A. Apply restraint so that the patient will not fall out of bed
A. high blood pressure B. Put a mouth gag so that the patient will not bite her tongue
B. swollen face, body and limb and the tongue will not fall back
C. inability to see in the dark C. Position the mother on her side to allow the
D. enlargement of the neck secretions to drain from her mouth and prevent
aspiration
58. In the nutritional assessment of grade 6 pupils, which of D. Check if the woman is also having a precipitate labor
the following nutritional assessment method is most
appropriate? 66. A gravido-cardiac mother is advised to observe bed rest
A. Height for age C. Body mass index primarily to
B. Weight for age D. Mid upper arm circumference A. Allow the fetus to achieve normal intrauterine growth
B. Minimize oxygen consumption which can aggravate
59. Pupils with below normal nutritional status are candidates the condition of the compromised heart of the mother
for a school feeding program. Which of the following is a C. Prevent perinatal infection
prerequisite for a child to be included in a feeding program? D. Reduce incidence of premature labor
A. Deworming
B. Parental consent 67. A pregnant mother is admitted to the hospital with the
C. Head to toe physical examination chief complaint of profuse vaginal bleeding, AOG 36 wks, not
D. Attendance in a nutritional class by a parent in labor. The nurse must always consider which of the following
precautions:
Situation: One of the trending news today is about the A. The internal exam is done only at the delivery under
Reproductive health bill. The following questions are strict asepsis with a double set-up
about the Philippine Reproductive Health. B. The preferred manner of delivering the baby is vaginal
60. The main objectives of Philippine Reproductive Health C. An emergency delivery set for vaginal delivery must be
includes the following: made ready before examining the patient
1. Reduce the maternal mortality rate D. Internal exam must be done following routine procedure
2. Reducing the child mortality
3. Halting and reversing the spread of HIV/AIDS 68. Before giving a repeat dose of magnesium sulfate to a
4. Increasing access to Reproductive health information pre-eclamptic patient, the nurse should assess the patient’s
services condition. Which of the following conditions will require the
5. Reduce paternal mortality to prostate cancer nurse to temporarily suspend a repeat dose of magnesium
sulfate?
A. All of the above C. All except 4 A. 100 cc urine output in 4 hours
B. All except 5 D. All except 3 B. Knee jerk reflex is (+) 2
C. Serum magnesium level is 10mEg/L.
61. According to this framework, the foremost intervention in D. Respiratory rate of 16/min
attaining reproductive health is:
A. Family planning C. Safe Sex Campaign Drive 69. Which of the following is TRUE in Rh incompatibility?
B. Counselling D. Maternal and Child Health and A. The condition can occur if the mother is Rh(+) and the fetus
Nutrition is Rh(-)
B. Every pregnancy of an Rh(-) mother will result to
62. Because of insufficient technical readiness and availability erythroblastosisfetalis
of resources, the DOH has focused in addressing the health C. On the first pregnancy of the Rh(-) mother, the fetus
concerns on the first four priority elements of the reproductive will not be affected
health namely: D. RhoGam is given only during the first pregnancy to prevent
1. Adolescent Reproductive health incompatibility
2. Family Planning
3. Prevention and Management of Reproductive Tract
Infection Including STIs and HIV/AIDS

TOP RANK REVIEW ACADEMY, INC. Page 5 | 8

Situation: Promotion of a healthy growth and client that the safest exercise to engage in is which of the
development as well as the prevention of diseases in following?
pediatric clients is one of the vital roles of a nurse. a. Swimming
70. Nurse Rolen is teaching parents about the nutritional needs
b. Scuba diving
of their 2 month old infant who is breastfeeding. Which
c. Low-impact gymnastics
response shows that the parent understands their infant’s
dietary needs? d. Bicycling with the legs in the air.
A. “We wont start any new foods now” 78. During her check-up, the physician prescribed
B. “ We’ll start the bay on skim milk” transvaginalsonography for Janice. She then asks the
C. “We’ll introduce cereal into her diet now” nurse about the procedure. The nurse tells her that:
D. “We should add new fruits to the diet at a time” a. The procedure takes about 2 hours
b. It will be necessary to drink 1 to 2 quarts of water
71. A mother is concerned that she might be spoiling her 2
month old daughter by picking her up each time she cries. before the examination.
Which suggestion should the nurse offer? c. Gel is spread over the abdomen, and a round disk
A. “If the baby’s diaper is dry when she is crying, leave her transducer will be moved over the abdomen to obtain
alone and she’ll fall asleep” the picture.
B. “Continue to pick her up when she cries because d. The probe that will be inserted into the vagina
young infants needs cuddling and holding to meet their will be covered with a disposable cover and
needs”
coated with a gel.
C. “Leave your baby alone for 10 minutes. If she hasn’t
stopped crying by then; pick her up” 79. The nurse also performed a nonstress test on Janice. The
D. “Crying at their age indicates hunger. Try feeding her when fetal monitor strip was viewed and was interpreted as
she cries” reactive and understands this as:
a. Normal findings
72. The nurse observes an infant in a playpen sitting up b. Abnormal findings
without support. He is playing with a plastic blocks and large
c. The need for further evaluation
plastic beads, bending over to pick them up, and changing
d. That the findings on the monitor were difficult to
them from one hand to the other. When another child hides a
toy behind the infants back, he does not attempt to look for it. interpret:
The nurse would be most correct in estimating the infant’s age
to be: 80. After a few days, she calls the nurse and reports that she
A. 4 months C. 8 months has noticed a thin, colorless vaginal discharge. The nurse
B. 6 months D. 10 months should make which statement to the client?
a. “Go to an Ob-Gyn immediately.”
73. In assessing an infant, the nurse should be aware that the
birth weight of infant triples by: b. “Report to the emergency department of the nearest
A. 5-6 months C. 30 months BeMONC center immediately.”
B. 12 months D. 3 years c. “The vaginal discharge may be bothersome, but
it is a normal occurrence.”
74. At 6 months, the following are expected to be observed d. “Use multiple maternity pads if the discharge is
from the baby except: bothersome, and change every 2 hours.”
A. She can sit without support
B. Teething
81. The Ballard Tool is used to assess for the gestational age
C. She starts eating solid foods
D. None of the above of a client. Which of the following statements on ratings is
not true?
SITUATION :Charge nurse Sugar has recently been a. An overall rating below the 10th percentile = Small for
assigned to manage a pulmonary progressive unit in St. gestational age (SGA)
Bernard’s Hospital, the best hospital in their region. For b. A rating between the 10th and 90th percentile =
the hospital and her career to be successful, she must
Appropriate for gestational age (AGA)
utilize her leadership skills appropriately.
c. A rating above the 90th percentile = Large for
75. The management was right, Sugar can comfortably shift gestation age (LGA)
her leadership styles considering her area of assignment and d. The rating is marked on a graph along with the
depending on the call of the situation. She has grown into a newborn’s weight and body circumference
flexible and well-rounded leader. She must have mastered only.
which leadership style now?
a. Participative c. Bureaucratic
82. Identify the parameter defined. It is elicited by flexing the
b. Ultraliberal d. Contingency
newborn’s hand toward the ventral forearm until
Situation: Janice went to a health center for her resistance is felt and measuring the angle.
prenatal check-up. She is a G3P2 mother. a. Arm recoil
76. A nurse is providing instructions to a client in the first b. Square window sign
trimester of pregnancy regarding measures to assist in c. Popliteal Angle
reducing breast tenderness. The nurse tells the client to: d. Scarf sign
a. Avoid wearing a bra. 83. One of your primary clients in the community is the Cruz
b. Wash the breast with warm water and keep family. They were selected because one of their children,
them dry. Jon, a 4 year old boy diagnosed with Down’s syndrome.
c. Wear tight-fitting blouses or dresses to provide They were referred to you for supportive care. How will
support. your approach be when assessing Cruz?
d. Wash the nipples and areolar area daily with soap, a. Treat him like a toddler and expect that he would
and massage the breasts with lotion. exhibit developmental attributes younger than his
77. Janice asks the nurse about the types of exercises that are chronological age.
allowable during pregnancy. The nurse should instruct the b. Treat him like a 4 year old and expect that he would
exhibit developmental attributes according to his age.

TOP RANK REVIEW ACADEMY, INC. Page 6 | 8

 c. Treat him on the basis of your assessment Situation: The goal of the Integrated Management of
findings. Childhood Illnesses is to significantly reduce global
d. Avoid handling the family as your primary patient. mortality and morbidity associated with major causes
84. You are assessing Alec, a 17-year-old college student for of diseases in children, and to contribute to healthy
his annual physical examination. When asked about his growth and development of children.
sexual activities, he admitted that he prefers to be in a 91. Which of the following are not components of the IMCI
relationship with persons of the same sex. However, he program?
could not express himself fully in fear of his parent’s a. Improving case management skills of healthcare
rejection, given that he is the eldest child who is to inherit workers
his family’s business. What psychosocial stage is being b. Pre-service and In-service training
compromised in this situation? c. Improving family and community practices.
a. Identity vs. role confusion d. All of the above
b. Intimacy vs. isolation e. None of the above
c. Integrity vs. despair 92. Which of the following is not a general danger sign?
d. Autonomy vs. shame and doubt a. Is the child able to drink or breast feed?
85. Which of the following car safety devices should be used b. Does the child vomit everything?
for a child who is 8 years old and is 4 feet tall? c. Has the child had a history of flu-like
a. Seat belt symptoms?
b. Booster seat d. Is the child abnormally sleepy or difficult to awaken?
c. Rear-facing convertible seat 93. Mutya is 15 months old. She weighs 8.5kg. Her
d.Front-facing convertible seat temperature is 35.5 degrees centigrade. She has been
coughing for 4 days, and is not eating well. This is her
Situation: Nurse Caring is caring for patients in the initial visit. Mutya’s mother said that she does not want to
community. She is focusing on the young population of breastfeed. The nurse offered Mutya some water. She was
the barangay. The following questions apply. too weak to lift her head. She was not able to drink from
86. A nurse assesses the vital signs of a 12-month-old infant the cup. She has not been vomiting and had no episodes
with a respiratory infection and notes that the respiratory rate of convulsions. She was not abnormally sleepy or difficult
is 35 breaths/min. Based on this finding, which action is to awaken. Which of the following main symptoms is
appropriate? applicable?
a. Administer oxygen. a. Cough c. Fever
b. Notify the physician. b. Diarrhea d. Ear problems
c. Document the findings. 94. Which of the following interventions is included for the
d. Reassess the respiratory rate in 15 minutes. treatment of mastoiditis?
87. A nurse is monitoring a 3-month-old infant for signs of a. Perform dry wicking
increased intracranial pressure. On palpation of the fontanels, b. Give Amoxicillin for 5 days
the nurse notes that the anterior fontanel is soft and flat. c. Give Quinolone otic drops for 14 days
Based on this finding, which nursing action is appropriate? d. Perform urgent referral.
a. Increase oral fluids. 95. For a child with severe dehydration, the following
b. Notify the physician. assessment findings are noted, except:
c. Document the finding. a. Absent tears
d. Elevate the head of the bed to 90 degrees. b. Skin pinch goes back slowly
88. A 16-year-old is admitted to the hospital for acute c. Lips and tongue are very dry
appendicitis and an appendectomy is performed. d. Child is lethargic and unconscious
Which nursing intervention is appropriate to facilitate normal SITUATION : A newly passed nurse is attending an
growth and development postoperatively? agency orientation regarding the nursing model of
a. Encourage the child to rest and read. practice implemented in the health care facility.
b. Encourage the parents to room inwith the child. 96. The nurse is told that the nursing model is a team nursing
approach. The nurse understands that planning care
c. Allow the child to interact with others in his or
delivery will be based on which characteristic of this type
her same age group. of nursing model of practice?
d. Allow the family to bring in the child’s favourite a. A task approach method is used to provide care to
computer games. clients
89. A mother arrives at a clinic with her toddler and tells a b. Managed care concepts and tools are used in
nurse that she has a difficult time getting the child to go to providing client care
bed at night. Which of the following is appropriate for the c. An RN leads nursing personnel in providing
care to a group of clients
nurse to suggest to the mother?
d. A single RN is responsible for providing nursing care
a. Avoid a nap during the day. to a group of clients
b. Allow the child to set bedtime limits. RATIONALE: C.In team nursing, nursing personnel are led by
c. Allow the child to have temper tantrums. a registered nurse leader in providing care to a group of
d. Inform the child of bedtime a few minutes clients. Option A identifies functional nursing. Option B
before it is time for bed. identifies a component of case management. Option D
90. A nurse is preparing to care for a 5-year-old who has been identifies primary nursing.
97. The nurse orientee acknowledges that in team nursing, the
placed in traction following a fracture of the femur. The nurse
most important principle of management exhibited is?
plans care, knowing that which of the following is the most a. Order c. Subordination of personal
appropriate activity for this child? interests
a. A radio b. Esprit de corps d. Equity
b. A sports video 98. The nurse manager has implemented a change in the
c. Large picture books method of the nursing delivery system from team to
functional nursing. The nurse orientee knows that
d. Crayons and a coloring book

TOP RANK REVIEW ACADEMY, INC. Page 7 | 8

 functional nursing employs which principle of management
according to Henri Fayol?
a. Unity of command c. Stability of
tenure
b. Remuneration d. Division of labor
99. The nurse orientee is now on the ICU/CCU for her special
area orientation. She recognized that a single nurse is
providing direct total care to a single patient. The care
delivery system applied in the ICU/CCU is?
a. Functional nursing c. Case method
b. Primary nursing d. Modular method
100. One week after her orientation in ICU/CCU, she is
permanently assigned by the chief nurse on the medical
ward. She observed that the care delivery system practiced
is somewhat a combination of primary and team nursing.
She correctly identifies this system as?
a. Modified team nursing c. Case method
b. Modified primary nursing d. Modular method

TOP RANK REVIEW ACADEMY, INC. Page 8 | 8