PNLE : Maternal and Child Health Nursing Exam 1

 PRACTICE MODE
 EXAM MODE
 TEXT MODE
Text Mode – Text version of the exam
1. A client asks the nurse what a third degree laceration is. She was informed that she had one. The
nurse explains that this is:

A. that extended their anal sphincter

B. through the skin and into the muscles
C. that involves anterior rectal wall
D. that extends through the perineal muscle.
2. Betina 30 weeks AOG discharged with a diagnosis of placenta previa. The nurse knows that the
client understands her care at home when she says:

A. I am happy to note that we can have sex occasionally when I have no bleeding.
B. I am afraid I might have an operation when my due comes
C. I will have to remain in bed until my due date comes
D. I may go back to work since I stay only at the office.
3. The uterus has already risen out of the pelvis and is experiencing farther into the abdominal area
at about the:

A. 8th week of pregnancy

B. 10th week of pregnancy
C. 12th week of pregnancy
D. 18th week of pregnancy
4. Which of the following urinary symptoms does the pregnant woman most frequently experience
during the first trimester:

A. frequency
B. dysuria
C. incontinence
D. burning
5. Mrs. Jimenez went to the health center for pre-natal check-up. the student nurse took her weight
and revealed 142 lbs. She asked the student nurse how much should she gain weight in her
pregnancy.

A. 20-30 lbs
B. 25-35 lbs
C. 30- 40 lbs
D. 10-15 lbs
6. The nurse is preparing Mrs. Jordan for cesarean delivery. Which of the following key concept
should the nurse consider when implementing nursing care?

A. Explain the surgery, expected outcome and kind of anesthetics.

B. Modify preoperative teaching to meet the needs of either a planned or emergency cesarean
birth.
C. Arrange for a staff member of the anesthesia department to explain what to expect post-
operatively.
D. Instruct the mother’s support person to remain in the family lounge until after the delivery.
7. Bettine Gonzales is hospitalized for the treatment of severe preecplampsia. Which of the following
represents an unusual finding for this condition?

A. generalized edema
B. proteinuria 4+
C. blood pressure of 160/110
D. convulsions
8. Nurse Geli explains to the client who is 33 weeks pregnant and is experiencing vaginal bleeding
that coitus:

A. Need to be modified in any way by either partner

B. Is permitted if penile penetration is not deep.
C. Should be restricted because it may stimulate uterine activity.
D. Is safe as long as she is in side-lying position.
9. Mrs. Precilla Abuel, a 32 year old mulripara is admitted to labor and delivery. Her last 3
pregnancies in short stage one of labor. The nurses decide to observe her closely. The physician
determines that Mrs. Abuel’s cervix is dilated to 6 cm. Mrs. Abuel states that she is extremely
uncomfortable. To lessen Mrs. Abuel’s discomfort, the nurse can advise her to:

A. lie face down

B. not drink fluids
C. practice holding breaths between contractions
D. assume Sim’s position
10. Which is true regarding the fontanels of the newborn?

A. The anterior is large in shape when compared to the posterior fontanel.

B. The anterior is triangular shaped; the posterior is diamond shaped.
C. The anterior is bulging; the posterior appears sunken.
D. The posterior closes at 18 months; the anterior closes at 8 to 12 months.
11. Mrs. Quijones gave birth by spontaneous delivery to a full term baby boy. After a minute after
birth, he is crying and moving actively. His birth weight is 6.8 lbs. What do you expect baby Quijones
to weigh at 6 months?

A. 13 -14 lbs
B. 16 -17 lbs
C. 22 -23 lbs
D. 27 -28 lbs
12. During the first hours following delivery, the post partum client is given IVF with oxytocin added
to them. The nurse understands the primary reason for this is:

A. To facilitate elimination
B. To promote uterine contraction
C. To promote analgesia
D. To prevent infection
13. Nurse Luis is assessing the newborn’s heart rate. Which of the following would be considered
normal if the newborn is sleeping?

A. 80 beats per minute

B. 100 beats per minute
C. 120 beats per minute
D. 140 beats per minute
14. The infant with Down Syndrome should go through which of the Erikson’s developmental stages
first?

A. Initiative vs. Self doubt

B. Industry vs. Inferiority
C. Autonomy vs. Shame and doubt
D. Trust vs. Mistrust
15. The child with phenylketonuria (PKU) must maintain a low phenylalanine diet to prevent which of
the following complications?

A. Irreversible brain damage

B. Kidney failure
C. Blindness
D. Neutropenia
16. Which age group is with imaginative minds and creates imaginary friends?

A. Toddler
B. Preschool
C. School
D. Adolescence
17. Which of the following situations would alert you to a potentially developmental problem with a
child?

A. Pointing to body parts at 15 months of age.

B. Using gesture to communicate at 18 months.
C. Cooing at 3 months.
D. Saying “mama” or “dada” for the first time at 18 months of age.
18. Isabelle, a 2 year old girl loves to move around and oftentimes manifests negativism and temper
tantrums. What is the best way to deal with her behavior?

A. Tell her that she would not be loved by others is she behaves that way..
B. Withholding giving her toys until she behaves properly.
C. Ignore her behavior as long as she does not hurt herself and others.
D. Ask her what she wants and give it to pacify her.
19. Baby boy Villanueva, 4 months old, was seen at the pediatric clinic for his scheduled check-up. By
this period, baby Villanueva has already increased his height by how many inches?

A. 3 inches
B. 4 inches
C. 5 inches
D. 6 inches
20. Alice, 10 years old was brought to the ER because of Asthma. She was immediately put under
aerosol administration of Terbutaline. After sometime, you observe that the child does not show any
relief from the treatment given. Upon assessment, you noticed that both the heart and respiratory
rate are still elevated and the child shows difficulty of exhaling. You suspect:

A. Bronchiectasis
B. Atelectasis
C. Epiglotitis
D. Status Asthmaticus
21. Nurse Jonas assesses a 2 year old boy with a tentative diagnosis of nephroblastoma. Symptoms
the nurse observes that suggest this problem include:

A. Lymphedema and nerve palsy

B. Hearing loss and ataxia
C. Headaches and vomiting
D. Abdominal mass and weakness
22. Which of the following danger sings should be reported immediately during the antepartum
period?

A. blurred vision
B. nasal stuffiness
C. breast tenderness
D. constipation
23. Nurse Jacob is assessing a 15 month old child with acute otitis media. Which of the following
symptoms would the nurse anticipate finding?

A. periorbital edema, absent light reflex and translucent tympanic membrane

B. irritability, purulent drainage in middle ear, nasal congestion and cough
C. diarrhea, retracted tympanic membrane and enlarged parotid gland
D. Vomiting, pulling at ears and pearly white tympanic membrane
24. Which of the following is the most appropriate intervention to reduce stress in a preterm infant at
33 weeks gestation?

A. Sensory stimulation including several senses at a time

B. tactile stimulation until signs of over stimulation develop
C. An attitude of extension when prone or side lying
D. Kangaroo care
25. The parent of a client with albinism would need to be taught which preventive healthcare
measure by the nurse:

A. Ulcerative colitis diet

B. Use of a high-SPF sunblock
C. Hair loss monitoring
D. Monitor for growth retardation
Answers and Rationales
1. (A) that extended their anal sphincter. Third degree laceration involves all in the second
degree laceration and the external sphincter of the rectum. Options B, C and D are under the
second degree laceration.
2. (C) I will have to remain in bed until my due date comes. Placenta previa means that the
placenta is the presenting part. On the first and second trimester there is spotting. On the third
trimester there is bleeding that is sudden, profuse and painless.
3. (D) 18th week of pregnancy. On the 8th week of pregnancy, the uterus is still within the pelvic
area. On the 10th week, the uterus is still within the pelvic area. On the 12th week, the uterus
and placenta have grown, expanding into the abdominal cavity. On the 18th week, the uterus
has already risen out of the pelvis and is expanding into the abdominal area.
4. (A) frequency. Pressure and irritation of the bladder by the growing uterus during the first
trimester is responsible for causing urinary frequency. Dysuria, incontinence and burning are
symptoms associated with urinary tract infection.
5. (B) 25-35 lbs. A weight gain of 11. 2 to 15.9 kg (25 to 35 lbs) is currently recommended as an
average weight gain in pregnancy. This weight gain consists of the following: fetus- 7.5 lb;
placenta- 1.5 lb; amniotic fluid- 2 lb; uterus- 2.5 lb; breasts- 1.5 to 3 lb; blood volume- 4 lb;
body fat- 7 lb; body fluid- 7 lb.
6. (B) Modify preoperative teaching to meet the needs of either a planned or emergency
cesarean birth. A key point to consider when preparing the client for a cesarean delivery is to
modify the preoperative teaching to meet the needs of either planned or emergency cesarean
birth, the depth and breadth of instruction will depend on circumstances and time available.
7. (D) convulsions. Options A, B and C are findings of severe preeclampsia. Convulsions is a
finding of eclampsia—an obstetrical emergency.
8. (C) Should be restricted because it may stimulate uterine activity.. Coitus is restricted when
there is watery discharge, uterine contraction and vaginal bleeding. Also those women with a
history of spontaneous miscarriage may be advised to avoid coitus during the time of pregnancy
when a previous miscarriage occurred.
9. (D) assume Sim’s position. When the woman is in Sim’s position, this puts the weight of the
fetus on bed, not on the woman and allows good circulation in the lower extremities.
10. (A) The anterior is large in shape when compared to the posterior fontanel.. The anterior
fontanel is larger in size than the posterior fontanel. Additionally, the anterior fontanel, which is
diamond shaped closes at 18 month, whereas the posterior fontanel, which is triangular in shape
closes at 8 to 12 weeks. Neither fontanel should appear bulging, which may indicate increases
ICP or sunken, which may indicate hydration.
11. (A) 13 -14 lbs. The birth weight of an infant is doubled at 6 months and is tripled at 12
months.
12. (B) To promote uterine contraction. Oxytocin is a hormone produced by the pituitary gland
that produces intermittent uterine contractions, helping to promote uterine involution.
13. (B) 100 beats per minute. The normal heart rate for a newborn that is sleeping is
approximately 100 beats per minute. If the newborn was awake, the normal heart rate would
range from 120 to 160 beats per minute.
14. (D) Trust vs. Mistrust. The child with Down syndrome will go through the same first stage,
trust vs. mistrust, only at a slow rate. Therefore, the nurse should concentrate on developing on
bond between the primary caregiver and the child.
15. (A) Irreversible brain damage. The child with PKU must maintain a strict low phenylalanine
diet to prevent central nervous system damage, seizures and eventual death.
16. (B) Preschool. During preschool, this is the time when children do imitative play, imaginative
play—the occurrence of imaginative playmates, dramatic play where children like to act, dance
and sing.
17. (D) Saying “mama” or “dada” for the first time at 18 months of age.. A child should say
“mama” or “dada” during 10 to 12 months of age. Options A, B and C are all normal assessments
of language development of a child.
18. (C) Ignore her behavior as long as she does not hurt herself and others.. If a child is trying to
get attention or trying to get something through tantrums—ignore his/her behavior.
19. (B) 4 inches. From birth to 6 months, the infant grows 1 inch (2.5 cm) per month. From 6 to
12 months, the infant grows ½ inch (1.25 cm) per month.
20. (D) Status Asthmaticus. Status asthmaticus leads to respiratory distress and bronchospasm
despite of treatment and interventions. Mechanical ventilation maybe needed due to respiratory
failure.
21. (D) Abdominal mass and weakness. Nephroblastoma or Wilm’s tumor is caused by
chromosomal abnormalities, most common kidney cancer among children characterized by
abdominal mass, hematuria, hypertension and fever.
22. (A) blurred vision. Danger signs that require prompt reporting are leaking of amniotic fluid,
blurred vision, vaginal bleeding, rapid weight gain and elevated blood pressure. Nasal stuffiness,
breast tenderness, and constipation are common discomforts associated with pregnancy.
23. (B) irritability, purulent drainage in middle ear, nasal congestion and cough. Irritability,
purulent drainage in middle ear, nasal congestion and cough, fever, loss of appetite, vomiting
and diarrhea are clinical manifestations of otitis media. Acute otitis media is common in children
6 months to 3 years old and 8 years old and above. Breast fed infants have higher resistance due
to protection of Eustachian tubes and middle ear from breast milk.
24. (D) Kangaroo care. Kangaroo care is the use of skin-to-skin contact to maintain body heat.
This method of care not only supplies heat but also encourages parent-child interaction.
25. (B) Use of a high-SPF sunblock. Without melanin production, the child with albinism is at risk
for severe sunburns. Maximum sun protection should be taken, including use of hats, long
sleeves, minimal time in the sun and high-SPF sunblock, to prevent any problems.
 NLE : Maternal and Child Health Nursing Exam 2

 PRACTICE MODE
 EXAM MODE
 TEXT MODE
Text Mode – Text version of the exam
1. Nurse Bella explains to a 28 year old pregnant woman undergoing a non-stress test that the test is
a way of evaluating the condition of the fetus by comparing the fetal heart rate with:

A. Fetal lie
B. Fetal movement
C. Maternal blood pressure
D. Maternal uterine contractions
2. During a 2 hour childbirth focusing on labor and delivery process for primigravida. The nurse
describes the second maneuver that the fetus goes through during labor progress when the head is
the presenting part as which of the following:

A. Flexion
B. Internal rotation
C. Descent
D. External rotation
3. Mrs. Jovel Diaz went to the hospital to have her serum blood test for alpha-fetoprotein. The nurse
informed her about the result of the elevation of serum AFP. The patient asked her what was the test
for:

A. Congenital Adrenal Hyperplasia

B. PKU
C. Down Syndrome
D. Neural tube defects
4. Fetal heart rate can be auscultated with a fetoscope as early as:

A. 5 weeks of gestation
B. 10 weeks of gestation
C. 15 weeks of gestation
D. 20 weeks of gestation
5. Mrs. Bendivin states that she is experiencing aching swollen, leg veins. The nurse would explain
that this is most probably the result of which of the following:

A. Thrombophlebitis
B. PIH
C. Pressure on blood vessels from the enlarging uterus
D. The force of gravity pulling down on the uterus
6. Mrs. Ella Santoros is a 25 year old primigravida who has Rheumatic heart disease lesion. Her
pregnancy has just been diagnosed. Her heart disease has not caused her to limit physical activity in
the past. Her cardiac disease and functional capacity classification is:

A. Class I
 B. Class II
C. Class III
D. class IV
7. The client asks the nurse, “When will this soft spot at the top of the head of my baby will close?”
The nurse should instruct the mother that the neonate’s anterior fontanel will normally close by age:

A. 2-3 months
B. 6-8 months
C. 10-12 months
D. 12-18 months
8. When a mother bleeds and the uterus is relaxed, soft and non-tender, you can account the cause
to:

A. Atony of the uterus

B. Presence of uterine scar
C. Laceration of the birth canal
D. Presence of retained placenta fragments
9. Mrs. Pichie Gonzales’s LMP began April 4, 2010. Her EDD should be which of the following:

A. February 11, 2011

B. January 11, 20111
C. December 12, 2010
D. Nowember 14, 2010
10. Which of the following prenatal laboratory test values would the nurse consider as significant?

A. Hematocrit 33.5%
B. WBC 8,000/mm3
C. Rubella titer less than 1:8
D. One hour glucose challenge test 110 g/dL
11. Aling Patricia is a patient with preeclampsia. You advise her about her condition, which would tell
you that she has not really understood your instructions?

A. “I will restrict my fat in my diet.”

B. “I will limit my activities and rest more frequently throughout the day.”
C. “I will avoid salty foods in my diet.”
D. “I will come more regularly for check-up.”
12. Mrs. Grace Evangelista is admitted with severe preeclampsia. What type of room should the
nurse select this patient?

A. A room next to the elevator.

B. The room farthest from the nursing station.
C. The quietest room on the floor.
D. The labor suite.
13. During a prenatal check-up, the nurse explains to a client who is Rh negative that RhoGAM will
be given:

A. Weekly during the 8th month because this is her third pregnancy.
B. During the second trimester, if amniocentesis indicates a problem.
C. To her infant immediately after delivery if the Coomb’s test is positive.
 D. Within 72 hours after delivery if infant is found to be Rh positive.
14. A baby boy was born at 8:50pm. At 8:55pm, the heart rate was 99 bpm. She has a weak cry,
irregular respiration. She was moving all extremities and only her hands and feet were still slightly
blue. The nurse should enter the APGAR score as:

A. 5
B. 6
C. 7
D. 8
15. Billy is a 4 year old boy who has an IQ of 140 which means:

A. average normal
B. very superior
C. above average
D. genius
16. A newborn is brought to the nursery. Upon assessment, the nurse finds that the child has short
palpebral fissures, thinned upper lip. Based on this data, the nurse suspects that the newborn is
MOST likely showing the effects of:

A. Chronic toxoplasmosis
B. Lead poisoning
C. Congenital anomalies
D. Fetal alcohol syndrome
17. A priority nursing intervention for the infant with cleft lip is which of the following:

A. Monitoring for adequate nutritional intake

B. Teaching high-risk newborn care
C. Assessing for respiratory distress
D. Preventing injury
18. Nurse Jacob is assessing a 12 year old who has hemophilia A. Which of the following assessment
findings would the nurse anticipate?

A. an excess of RBC
B. an excess of WBC
C. a deficiency of clotting factor VIII
D. a deficiency of clotting factor IX
19. Celine, a mother of a 2 year old tells the nurse that her child “cries and has a fit when I have to
leave him with a sitter or someone else.” Which of the following statements would be the nurse’s
most accurate analysis of the mother’s comment?

A. The child has not experienced limit-setting or structure.

B. The child is expressing a physical need, such as hunger.
C. The mother has nurtured overdependence in the child.
D. The mother is describing her child’s separation anxiety.
20. Mylene Lopez, a 16 year old girl with scoliosis has recently received an invitation to a pool party.
She asks the nurse how she can disguise her impairment when dressed in a bathing suit. Which
nursing diagnosis can be justified by Mylene’s statement?

A. Anxiety
 B. Body image disturbance
C. Ineffective individual coping
D. Social isolation
21. The foul-smelling, frothy characteristic of the stool in cystic fibrosis results from the presence of
large amounts of which of the following:

A. sodium and chloride

B. undigested fat
C. semi-digested carbohydrates
D. lipase, trypsin and amylase
22. Which of the following would be a disadvantage of breast feeding?

A. involution occurs rapidly

B. the incidence of allergies increases due to maternal antibodies
C. the father may resent the infant’s demands on the mother’s body
D. there is a greater chance of error during preparation
23. A client is noted to have lymphedema, webbed neck and low posterior hairline. Which of the
following diagnoses is most appropriate?

A. Turner’s syndrome
B. Down’s syndrome
C. Marfan’s syndrome
D. Klinefelter’s syndrome
24. A 4 year old boy most likely perceives death in which way:

A. An insignificant event unless taught otherwise

B. Punishment for something the individual did
C. Something that just happens to older people
D. Temporary separation from the loved one.
25. Catherine Diaz is a 14 year old patient on a hematology unit who is being treated for sickle cell
crisis. During a crisis such as that seen in sickle cell anemia, aldosterone release is stimulated. In
what way might this influence Catherine’s fluid and electrolyte balance?

A. sodium loss, water loss and potassium retention

B. sodium loss, water los and potassium loss
C. sodium retention, water loss and potassium retention
D. sodium retention, water retention and potassium loss
Answers and Rationales
1. (B) Fetal movement. Non-stress test measures response of the FHR to the fetal movement.
With fetal movement, FHR increase by 15 beats and remain for 15 seconds then decrease to
average rate. No increase means poor oxygenation perfusion to fetus.
2. (A) Flexion. The 6 cardinal movements of labor are descent, flexion, internal rotation,
extension, external rotation and expulsion.
3. (D) Neural tube defects. Alpha-fetoprotein is a substance produces by the fetal liver that is
present in amniotic fluid and maternal serum. The level is abnormally high in the maternal serum
if the fetus has an open spinal or abdominal defect because the open defect allows more AFP to
appear.
4. (D) 20 weeks of gestation. The FHR can be auscultated with a fetoscope at about 20 weeks of
gestation. FHR is usually auscultated at the midline suprapubic region with Doppler ultrasound at
10 to 12 weeks of gestation. FHR cannot be heard any earlier than 10 weeks of gestation.
5. (C) Pressure on blood vessels from the enlarging uterus. Pressure of the growing fetus on
blood vessels results in an increase risk for venous stasis in the lower extremities. Subsequently,
edema and varicose vein formation may occur.
6. (A) Class I. Clients under class I has no physical activity limitation. There is a slight limitation
of physical activity in class II, ordinary activity causes fatigue, palpitation, dyspnea or angina.
Class III is moderate limitation of physical activity; less than ordinary activity causes fatigue.
Unable to carry on any activity without experiencing discomfort is under class IV.
7. (D) 12-18 months. Anterior fontanel closes at 12-18 months while posterior fontanel closes at
birth until 2 months.
8. (A) Atony of the uterus. Uterine atony, or relaxation of the uterus is the most frequent cause
of postpartal hemorrhage. It is the inability to maintain the uterus in contracted state.
9. (B) January 11, 20111. Using the Nagel’s rule, he use this formula ( -3 calendar months + 7
days).
10. (C) Rubella titer less than 1:8. A rubella titer should be 1:8 or greater. Thus, a finding of a
titer less than 1:8 is significant, indicating that the client may not possess immunity to rubella. A
hematocrit of 33.5%, WBC of 8,000/mm3, and a 1 hour glucose challenge test of 110 g/dL are
within normal parameters.
11. (B) “I will limit my activities and rest more frequently throughout the day.”Pregnant woman
with preeclampsia should be in a complete bed rest. When body is in recumbent position, sodium
tends to be excreted at a faster rate. It is the best method of aiding increased excretion of
sodium and encouraging diuresis. Rest should always be in a lateral recumbent position to avoid
uterine pressure on the vena cava and prevent supine hypotension.
12. (C) The quietest room on the floor.A loud noise such as a crying baby, or a dropped tray of
equipment may be sufficient to trigger a seizure initiating eclampsia, a woman with severe
preeclampsia should be admiotted to a private room so she can rest as undisturbed as possible.
Darken the room if possible because bright light can trigger seizures.
13. (D) Within 72 hours after delivery if infant is found to be Rh positive. RhoGAM is given to Rh-
negative mothers within 72 hours after birth of Rh-positive baby to prevent development of
antibodies in the maternal blood stream, which will be fata to succeeding Rh-positive offspring.
14. (B) 6. Heart rate of 99 bpm-1; weak cry-1; irregular respiration-1; moving all extremities-2;
extremities are slightly blue-1; with a total score of 6.
15. (D) genius. IQ= mental age/chronological age x 100. Mental age refers to the typical
intelligence level found for people at a give chronological age. OQ of 140 and above is
considered genius.
16. (D) Fetal alcohol syndrome. The newborn with fetal alcohol syndrome has a number of
possible problems at birth. Characteristics that mark the syndrome include pre and postnatal
growth retardation; CNS involvement such as cognitive challenge, microcephally and cerebral
palsy; and a distinctive facial feature of a short palpebral fissure and thin upper lip.
17. (A) Monitoring for adequate nutritional intake. The infant with cleft lip is unable to create an
adequate seal for sucking. The child is at risk for inadequate nutritional intake as well as
aspiration.
18. (C) a deficiency of clotting factor VIII. Hemophillia A (classic hemophilia) is a deficiency in
factor VIII (an alpha globulin that stabilizes fibrin clots).
19. (D) The mother is describing her child’s separation anxiety. Before coming to any conclusion,
the nurse should ask the mother focused questions; however, based on initial information, the
analysis of separation anxiety would be most valid. Separation anxiety is a normal toddler
 response. When the child senses he is being sent away from those who most provide him with
love and security. Crying is one way a child expresses a physical need; however, the nurse would
be hasty in drawing this as first conclusion based on what the mother has said. Nurturing
overdependence or not providing structure for the toddler are inaccurate conclusions based on
the information provided.
20. (B) Body image disturbance. Mylene is experiencing uneasiness about the curvative of her
spine, which will be more evident when she wears a bathing suit. This data suggests a body
image disturbance. There is no evidence of anxiety or ineffective coping. The fact that Mylene is
planning to attend a pool party dispels a diagnosis of social isolation.
21. (B) undigested fat. The client with cystic fibrosis absorbs fat poorly because of the think
secretions blocking the pancreatic duct. The lack of natural pancreatic enzyme leads to poor
absorption of predominantly fats in the duodenum. Foul-smelling, frothy stool is termed
steatorrhea.
22. (C) the father may resent the infant’s demands on the mother’s body. With breast feeding, the
father’s body is not capable of providing the milk for the newborn, which may interfere with
feeding the newborn, providing fewer chances for bonding, or he may be jealous of the infant’s
demands on his wife time and body. Breast feeding is advantageous because uterine involution
occurs more rapidly, thus minimizing blood loss. The presence of maternal antibodies in breast
milk helps decrease the incidence of allergies in the newborn. A greater chance for error is
associated with bottle feeding. No preparation required for breast feeding.
23. (A) Turner’s syndrome. Lymphedema, webbed neck and low posterior hairline, these are the 3
key assessment features in Turner’s syndrome. If the child is diagnosed early in age, proper
treatment can be offered to the family. All newborns should be screened for possible congenital
defects.
24. (D) Temporary separation from the loved one. The predominant perception of death by
preschool age children is that death is temporary separation. Because that child is losing
someone significant and will not see that person again, it’s inaccurate to infer death is
insignificant, regardless of the child’s response.
25. (D) sodium retention, water retention and potassium loss. Stress stimulates the adrenal cortex
to increase the release of aldosterone. Aldosterone promotes the resorption of sodium, the
retention of water and the loss of potassium.
 PNLE : Maternal and Child Health Nursing Exam 3

 PRACTICE MODE
 EXAM MODE
 TEXT MODE
Text Mode – Text version of the exam
1. A pregnant woman who is at term is admitted to the birthing unit in active labor. The client has
only progressed from 2cm to 3 cm in 8 hours. She is diagnosed with hypotonic dystocia and the
physician ordered Oxytocin (Pitocin) to augment her contractions. Which of the following is the most
important aspect of nursing intervention at this time?

A. Timing and recording length of contractions.

B. Monitoring.
C. Preparing for an emergency cesarean birth.
D. Checking the perineum for bulging.
2. A client who hallucinates is not in touch with reality. It is important for the nurse to:

A. Isolate the client from other patients.

B. Maintain a safe environment.
C. Orient the client to time, place, and person.
D. Establish a trusting relationship.
3. The nurse is caring to a child client who has had a tonsillectomy. The child complains of having
dryness of the throat. Which of the following would the nurse give to the child?

A. Cola with ice

B. Yellow noncitrus Jello
C. Cool cherry Kool-Aid
D. A glass of milk
4. The physician ordered Phenylephrine (Neo-Synephrine) nasal spray to a 13-year-old client. The
nurse caring to the client provides instructions that the nasal spray must be used exactly as directed
to prevent the development of:

A. Increased nasal congestion.

B. Nasal polyps.
C. Bleeding tendencies.
D. Tinnitus and diplopia.
5. A client with tuberculosis is to be admitted in the hospital. The nurse who will be assigned to care
for the client must institute appropriate precautions. The nurse should:

A. Place the client in a private room.

B. Wear an N 95 respirator when caring for the client.
C. Put on a gown every time when entering the room.
D. Don a surgical mask with a face shield when entering the room.
6. Which of the following is the most frequent cause of noncompliance to the medical treatment of
open-angle glaucoma?

A. The frequent nausea and vomiting accompanying use of miotic drug.

 B. Loss of mobility due to severe driving restrictions.
C. Decreased light and near-vision accommodation due to miotic effects of pilocarpine.
D. The painful and insidious progression of this type of glaucoma.
7. In the morning shift, the nurse is making rounds in the nursing care units. The nurse enters in a
client’s room and notes that the client’s tube has become disconnected from the Pleurovac. What
would be the initial nursing action?

A. Apply pressure directly over the incision site.

B. Clamp the chest tube near the incision site.
C. Clamp the chest tube closer to the drainage system.
D. Reconnect the chest tube to the Pleurovac.
8. Which of the following complications during a breech birth the nurse needs to be alarmed?

A. Abruption placenta.
B. Caput succedaneum.
C. Pathological hyperbilirubinemia.
D. Umbilical cord prolapse.
9. The nurse is caring to a client diagnosed with severe depression. Which of the following nursing
approach is important in depression?

A. Protect the client against harm to others.

B. Provide the client with motor outlets for aggressive, hostile feelings.
C. Reduce interpersonal contacts.
D. Deemphasizing preoccupation with elimination, nourishment, and sleep.
10. A 3-month-old client is in the pediatric unit. During assessment, the nurse is suspecting that the
baby may have hypothyroidism when mother states that her baby does not:

A. Sit up.
B. Pick up and hold a rattle.
C. Roll over.
D. Hold the head up.
11. The physician calls the nursing unit to leave an order. The senior nurse had conversation with the
other staff. The newly hired nurse answers the phone so that the senior nurses may continue their
conversation. The new nurse does not knowthe physician or the client to whom the order pertains.
The nurse should:

A. Ask the physician to call back after the nurse has read the hospital policy manual.
B. Take the telephone order.
C. Refuse to take the telephone order.
D. Ask the charge nurse or one of the other senior staff nurses to take the telephone order.
12. The staff nurse on the labor and delivery unit is assigned to care to a primigravida in transition
complicated by hypertension. A new pregnant woman in active labor is admitted in the same unit.
The nurse manager assigned the same nurse to the second client. The nurse feels that the client with
hypertension requires one-to-one care. What would be the initial actionof the nurse?

A. Accept the new assignment and complete an incident report describing a shortage of nursing
staff.
B. Report the incident to the nursing supervisor and request to be floated.
C. Report the nursing assessment of the client in transitional labor to the nurse manager and
discuss misgivings about the new assignment.
D. Accept the new assignment and provide the best care.
13. A newborn infant with Down syndrome is to be discharged today. The nurse is preparing to give
the discharge teaching regarding the proper care at home. The nurse would anticipate that the
mother is probably at the:

A. 40 years of age.
B. 20 years of age.
C. 35 years of age.
D. 20 years of age.
14. The emergency department has shortage of staff. The nurse manager informs the staff nurse in
the critical care unit that she has to float to the emergency department. What should the staff nurse
expect under these conditions?

A. The float staff nurse will be informed of the situation before the shift begins.
B. The staff nurse will be able to negotiate the assignments in the emergency department.
C. Cross training will be available for the staff nurse.
D. Client assignments will be equally divided among the nurses.
15. The nurse is assigned to care for a child client admitted in the pediatrics unit. The client is
receiving digoxin. Which of the following questions will be asked by the nurse to the parents of the
child in order to assess the client’s risk for digoxin toxicity?

A. “Has he been exposed to any childhood communicable diseases in the past 2-3 weeks?”
B. “Has he been taking diuretics at home?”
C. “Do any of his brothers and sisters have history of cardiac problems?”
D. “Has he been going to school regularly?”
16. The nurse noticed that the signed consent form has an error. The form states, “Amputation of
the right leg” instead of the left leg that is to be amputated. The nurse has administered already the
preoperative medications. What should the nurse do?

A. Call the physician to reschedule the surgery.

B. Call the nearest relative to come in to sign a new form.
C. Cross out the error and initial the form.
D. Have the client sign another form.
17. The nurse in the nursing care unit checks the fluctuation in the water-seal compartment of a
closed chest drainage system. The fluctuation has stopped, the nurse would:

A. Vigorously strip the tube to dislodge a clot.

B. Raise the apparatus above the chest to move fluid.
C. Increase wall suction above 20 cm H2O pressure.
D. Ask the client to cough and take a deep breath.
18. The pediatric nurse in the neonatal unit was informed that the baby that is brought to the mother
in the hospital room is wrong. The nurse determines that two babies were placed in the wrong cribs.
The most appropriate nursing action would be to:

A. Determine who is responsible for the mistake and terminate his or her employment.
B. Record the event in an incident/variance report and notify the nursing supervisor.
C. Reassure both mothers, report to the charge nurse, and do not record.
 D. Record detailed notes of the event on the mother’s medical record.
19. Before the administration of digoxin, the nurse completes an assessment to a toddler client for
signs and symptoms of digoxin toxicity. Which of the following is the earliest and most significant
sign of digoxin toxicity?

A. Tinnitus
B. Nausea and vomiting
C. Vision problem
D. Slowing in the heart rate
20. Which of the following treatment modality is appropriate for a client with paranoid tendency?

A. Activity therapy.
B. Individual therapy.
C. Group therapy.
D. Family therapy.
21. The client with rheumatoid arthritis is for discharge. In preparing the client for discharge on
prednisone therapy, the nurse should advise the client to:

A. Wear sunglasses if exposed to bright light for an extended period of time.

B. Take oral preparations of prednisone before meals.
C. Have periodic complete blood counts while on the medication.
D. Never stop or change the amount of the medication without medical advice.
22. A pregnant client tells the nurse that she is worried about having urinary frequency. What will be
the most appropriate nursing response?

A. “Try using Kegel (perineal) exercises and limiting fluids before bedtime. If you have frequency
associated with fever, pain on voiding, or blood in the urine, call your doctor/nurse-midwife.
B. “Placental progesterone causes irritability of the bladder sphincter. Your symptoms will go
away after the baby comes.”
C. “Pregnant women urinate frequently to get rid of fetal wastes. Limit fluids to 1L/daily.”
D. “Frequency is due to bladder irritation from concentrate urine and is normal in pregnancy.
Increase your daily fluid intake to 3L.”
23. Which of the following will help the nurse determine that the expression of hostility is useful?

A. Expression of anger dissipates the energy.

B. Energy from anger is used to accomplish what needs to be done.
C. Expression intimidates others.
D. Degree of hostility is less than the provocation.
24. The nurse is providing an orientation regarding case management to the nursing students. Which
characteristics should the nurse include in the discussion in understanding case management?

A. Main objective is a written plan that combines discipline-specific processes used to measure
outcomes of care.
B. Main purpose is to identify expected client, family and staff performance against the timeline
for clients with the same diagnosis.
C. Main focus is comprehensive coordination of client care, avoid unnecessary duplication of
services, improve resource utilization and decrease cost.
D. Primary goal is to understand why predicted outcomes have not been met and the correction
of identified problems.
25. The physician orders a dose of IV phenytoin to a child client. In preparing in the administration of
the drug, which nursing action is not correct?

A. Infuse the phenytoin into a smaller vein to prevent purple glove syndrome.
B. Check the phenytoin solution to be sure it is clear or light yellow in color, never cloudy.
C. Plan to give phenytoin over 30-60 minutes, using an in-line filter.
D. Flush the IV tubing with normal saline before starting phenytoin.
26. The pregnant woman visits the clinic for check –up. Which assessment findings will help the
nurse determine that the client is in 8-week gestation?

A. Leopold maneuvers.
B. Fundal height.
C. Positive radioimmunoassay test (RIA test).
D. Auscultation of fetal heart tones.
27. Which of the following nursing intervention is essential for the client who had pneumonectomy?

A. Medicate for pain only when needed.

B. Connect the chest tube to water-seal drainage.
C. Notify the physician if the chest drainage exceeds 100mL/hr.
D. Encourage deep breathing and coughing.
28. The nurse is providing a health teaching to a group of parents regarding Chlamydia trachomatis.
The nurse is correct in the statement, “Chlamydia trachomatis is not only an intracellular bacterium
that causes neonatal conjunctivitis, but it also can cause:

A. Discoloration of baby and adult teeth.

B. Pneumonia in the newborn.
C. Snuffles and rhagades in the newborn.
D. Central hearing defects in infancy.
29. The nurse is assigned to care to a 17-year-old male client with a history of substance abuse. The
client asks the nurse, “Have you ever tried or used drugs?” The most correct response of the nurse
would be:

A. “Yes, once I tried grass.”

B. “No, I don’t think so.”
C. “Why do you want to know that?”
D. “How will my answer help you?”
30. Which of the following describes a health care team with the principles of participative
leadership?

A. Each member of the team can independently make decisions regarding the client’s care
without necessarily consulting the other members.
B. The physician makes most of the decisions regarding the client’s care.
C. The team uses the expertise of its members to influence the decisions regarding the client’s
care.
D. Nurses decide nursing care; physicians decide medical and other treatment for the client.
31. A nurse is giving a health teaching to a woman who wants to breastfeed her newborn baby.
Which hormone, normally secreted during the postpartum period, influences both the milk ejection
reflex and uterine involution?
 A. Oxytocin.
B. Estrogen.
C. Progesterone.
D. Relaxin.
32. One staff nurse is assigned to a group of 5 patients for the 12-hour shift. The nurse is responsible
for the overall planning, giving and evaluating care during the entire shift. After the shift, same
responsibility will be endorsed to the next nurse in charge. This describes nursing care delivered via
the:

A. Primary nursing method.

B. Case method.
C. Functional method.
D. Team method.
33. The ambulance team calls the emergency department that they are going to bring a client who
sustained burns in a house fire. While waiting for the ambulance, the nurse will anticipate emergency
care to include assessment for:

A. Gas exchange impairment.

B. Hypoglycemia.
C. Hyperthermia.
D. Fluid volume excess.
34. Most couples are using “natural” family planning methods. Most accidental pregnancies in couples
preferred to use this method have been related to unprotected intercourse before ovulation. Which of
the following factor explains why pregnancy may be achieved by unprotected intercourse during the
preovulatory period?

A. Ovum viability.
B. Tubal motility.
C. Spermatozoal viability.
D. Secretory endometrium.
35. An older adult client wakes up at 2 o’clock in the morning and comes to the nurse’s station
saying, “I am having difficulty in sleeping.” What is the best nursing response to the client?

A. “I’ll give you a sleeping pill to help you get more sleep now.”
B. “Perhaps you’d like to sit here at the nurse’s station for a while.”
C. “Would you like me to show you where the bathroom is?”
D. “What woke you up?”
36. The nurse is taking care of a multipara who is at 42 weeks of gestation and in active labor, her
membranes ruptured spontaneously 2 hours ago. While auscultating for the point of maximum
intensity of fetal heart tones before applying an external fetal monitor, the nurse counts 100 beats
per minute. The immediate nursing action is to:

A. Start oxygen by mask to reduce fetal distress.

B. Examine the woman for signs of a prolapsed cord.
C. Turn the woman on her left side to increase placental perfusion.
D. Take the woman’s radial pulse while still auscultating the FHR.
37. The nurse must instruct a client with glaucoma to avoid taking over-the-counter medications like:

A. Antihistamines.
 B. NSAIDs.
C. Antacids.
D. Salicylates.
38. A male client is brought to the emergency department due to motor vehicle accident. While
monitoring the client, the nurse suspects increasing intracranial pressure when:

A. Client is oriented when aroused from sleep, and goes back to sleep immediately.
B. Blood pressure is decreased from 160/90 to 110/70.
C. Client refuses dinner because of anorexia.
D. Pulse is increased from 88-96 with occasional skipped beat.
39. The nurse is conducting a lecture to a class of nursing students about advance directives to
preoperative clients. Which of the following statement by the nurse js correct?

A. “The spouse, but not the rest of the family, may override the advance directive.”
B. “An advance directive is required for a “do not resuscitate” order.”
C. “A durable power of attorney, a form of advance directive, may only be held by a blood
relative.”
D. “The advance directive may be enforced even in the face of opposition by the spouse.”
40. A client diagnosed with schizophrenia is shouting and banging on the door leading to the outside,
saying, “I need to go to an appointment.” What is the appropriate nursing intervention?

A. Tell the client that he cannot bang on the door.

B. Ignore this behavior.
C. Escort the client going back into the room.
D. Ask the client to move away from the door.
41. Which of the following action is an accurate tracheal suctioning technique?

A. 25 seconds of continuous suction during catheter insertion.

B. 20 seconds of continuous suction during catheter insertion.
C. 10 seconds of intermittent suction during catheter withdrawal.
D. 15 seconds of intermittent suction during catheter withdrawal.
42. The client’s jaw and cheekbone is sutured and wired. The nurse anticipates that the most
important thing that must be ready at the bedside is:

A. Suture set.
B. Tracheostomy set.
C. Suction equipment.
D. Wire cutters.
43. A mother is in the third stage of labor. Which of the following signs will help the nurse determine
the signs of placental separation?

A. The uterus becomes globular.

B. The umbilical cord is shortened.
C. The fundus appears at the introitus.
D. Mucoid discharge is increased.
44. After therapy with the thrombolytic alteplase (t-PA), what observation will the nurse report to the
physician?

A. 3+ peripheral pulses.
 B. Change in level of consciousness and headache.
C. Occasional dysrhythmias.
D. Heart rate of 100/bpm.
45. A client who undergone left nephrectomy has a large flank incision. Which of the following
nursing action will facilitate deep breathing and coughing?

A. Push fluid administration to loosen respiratory secretions.

B. Have the client lie on the unaffected side.
C. Maintain the client in high Fowler’s position.
D. Coordinate breathing and coughing exercise with administration of analgesics.
46. The community nurse is teaching the group of mothers about the cervical mucus method of
natural family planning. Which characteristics are typical of the cervical mucus during the “fertile”
period of the menstrual cycle?

A. Absence of ferning.
B. Thin, clear, good spinnbarkeit.
C. Thick, cloudy.
D. Yellow and sticky.
47. A client with ruptured appendix had surgery an hour ago and is transferred to the nursing care
unit. The nurse placed the client in a semi-Fowler’s position primarily to:

A. Facilitate movement and reduce complications from immobility.

B. Fully aerate the lungs.
C. Splint the wound.
D. Promote drainage and prevent subdiaphragmatic abscesses.
48. Which of the following will best describe a management function?

A. Writing a letter to the editor of a nursing journal.

B. Negotiating labor contracts.
C. Directing and evaluating nursing staff members.
D. Explaining medication side effects to a client.
49. The parents of an infant client ask the nurse to teach them how to administer Cortisporin eye
drops. The nurse is correct in advising the parents to place the drops:

A. In the middle of the lower conjunctival sac of the infant’s eye.

B. Directly onto the infant’s sclera.
C. In the outer canthus of the infant’s eye.
D. In the inner canthus of the infant’s eye.
50. The nurse is assessing on the client who is admitted due to vehicle accident. Which of the
following findings will help the nurse that there is internal bleeding?

A. Frank blood on the clothing.

B. Thirst and restlessness.
C. Abdominal pain.
D. Confusion and altered of consciousness.
51. The nurse is completing an assessment to a newborn baby boy. The nurse observes that the skin
of the newborn is dry and flaking and there are several areas of an apparent macular rash. The nurse
charts this as:
 A. Icterus neonatorum
B. Multiple hemangiomas
C. Erythema toxicum
D. Milia
52. The client is brought to the emergency department because of serious vehicle accident. After an
hour, the client has been declared brain dead. The nurse who has been with the client must now talk
to the family about organ donation. Which of the following consideration is necessary?

A. Include as many family members as possible.

B. Take the family to the chapel.
C. Discuss life support systems.
D. Clarify the family’s understanding of brain death.
53. The nurse is teaching exercises that are good for pregnant women increasing tone and fitness
and decreasing lower backache. Which of the following should the nurse exclude in the exercise
program?

A. Stand with legs apart and touch hands to floor three times per day.
B. Ten minutes of walking per day with an emphasis on good posture.
C. Ten minutes of swimming or leg kicking in pool per day.
D. Pelvic rock exercise and squats three times a day.
54. A client with obsessive-compulsive behavior is admitted in the psychiatric unit. The nurse taking
care of the client knows that the primary treatment goal is to:

A. Provide distraction.
B. Support but limit the behavior.
C. Prohibit the behavior.
D. Point out the behavior.
55. After ileostomy, the nurse expects that the drainage appliance will be applied to the stoma:

A. When the client is able to begin self-care procedures.

B. 24 hours later, when the swelling subsided.
C. In the operating room after the ileostomy procedure.
D. After the ileostomy begins to function.
56. A female client who has a 28-day menstrual cycle asks the community health nurse when she get
pregnant during her cycle. What will be the best nursing response?

A. It is impossible to determine the fertile period reliably. So it is best to assume that a woman is
always fertile.
B. In a 28-day cycle, ovulation occurs at or about day 14. The egg lives for about 24 hours and
the sperm live for about 72 hours. The fertile period would be approximately between day 11
and day 15.
C. In a 28- day cycle, ovulation occurs at or about day 14. The egg lives for about 72 hours and
the sperm live for about 24 hours. The fertile period would be approximately between day 13
and 17.
D. In a 28-day cycle, ovulation occurs 8 days before the next period or at about day 20. The
fertile period is between day 20 and the beginning of the next period.
57. Which of the following statement describes the role of a nurse as a client advocate?

A. A nurse may override clients’ wishes for their own good.

 B. A nurse has the moral obligation to prevent harm and do well for clients.
C. A nurse helps clients gain greater independence and self-determination.
D. A nurse measures the risk and benefits of various health situations while factoring in cost.
58. A community health nurse is providing a health teaching to a woman infected with herpes
simplex 2. Which of the following health teaching must the nurse include to reduce the chances of
transmission of herpes simplex 2?

A. “Abstain from intercourse until lesions heal.”

B. “Therapy is curative.”
C. “Penicillin is the drug of choice for treatment.”
D. “The organism is associated with later development of hydatidiform mole.
59. The nurse in the psychiatric ward informed the male client that he will be attending the 9:00 AM
group therapy sessions. The client tells the nurse that he must wash his hands from 9:00 to 9:30 AM
each day and therefore he cannot attend. Which concept does the nursing staff need to keep in mind
in planning nursing intervention for this client?

A. Depression underlines ritualistic behavior.

B. Fear and tensions are often expressed in disguised form through symbolic processes.
C. Ritualistic behavior makes others uncomfortable.
D. Unmet needs are discharged through ritualistic behavior.
60. The nurse assesses the health condition of the female client. The client tells the nurse that she
discovered a lump in the breast last year and hesitated to seek medical advice. The nurse
understands that, women who tend to delay seeking medical advice after discovering the disease are
displaying what common defense mechanism?

A. Intellectualization.
B. Suppression.
C. Repression.
D. Denial.
61. Which of the following situations cannot be delegated by the registered nurse to the nursing
assistant?

A. A postoperative client who is stable needs to ambulate.

B. Client in soft restraint who is very agitated and crying.
C. A confused elderly woman who needs assistance with eating.
D. Routine temperature check that must be done for a client at end of shift.
62. In the admission care unit, which of the following client would the nurse give immediate
attention?

A. A client who is 3 days postoperative with left calf pain.

B. A client who is postoperative hip pinning who is complaining of pain.
C. New admitted client with chest pain.
D. A client with diabetes who has a glucoscan reading of 180.
63. A couple seeks medical advice in the community health care unit. A couple has been unable to
conceive; the man is being evaluated for possible problems. The physician ordered semen analysis.
Which of the following instructions is correct regarding collection of a sperm specimen?

A. Collect a specimen at the clinic, place in iced container, and give to laboratory personnel
immediately.
 B. Collect specimen after 48-72 hours of abstinence and bring to clinic within 2 hours.
C. Collect specimen in the morning after 24 hours of abstinence and bring to clinic immediately.
D. Collect specimen at night, refrigerate, and bring to clinic the next morning.
64. The physician ordered Betamethasone to a pregnant woman at 34 weeks of gestation with sign
of preterm labor. The nurse expects that the drug will:

A. Treat infection.
B. Suppress labor contraction.
C. Stimulate the production of surfactant.
D. Reduce the risk of hypertension.
65. A tracheostomy cuff is to be deflated, which of the following nursing intervention should be
implemented before starting the procedures?

A. Suction the trachea and mouth.

B. Have the obdurator available.
C. Encourage deep breathing and coughing.
D. Do a pulse oximetry reading.
66. A client is diagnosed with Tuberculosis and respiratory isolation is initiated. This means that:

A. Gloves are worn when handling the client’s tissue, excretions, and linen.
B. Both client and attending nurse must wear masks at all times.
C. Nurse and visitors must wear masks until chemotherapy is begun. Client is instructed in cough
and tissue techniques.
D. Full isolation; that is, caps and gowns are required during the period of contagion.
67. A client with lung cancer is admitted in the nursing care unit. The husband wants to know the
condition of his wife. How should the nurse respond to the husband?

A. Find out what information he already has.

B. Suggest that he discuss it with his wife.
C. Refer him to the doctor.
D. Refer him to the nurse in charge.
68. A hospitalized client cannot find his handkerchief and accuses other cient in the room and the
nurse of stealing them. Which is the most therapeutic approach to this client?

A. Divert the client’s attention.

B. Listen without reinforcing the client’s belief.
C. Inject humor to defuse the intensity.
D. Logically point out that the client is jumping to conclusions.
69. After a cystectomy and formation of an ileal conduit, the nurse provides instruction regarding
prevention of leakage of the pouch and backflow of the urine. The nurse is correct to include in the
instruction to empty the urine pouch:

A. Every 3-4 hours.

B. Every hour.
C. Twice a day.
D. Once before bedtime.
70. Which telephone call from a student’s mother should the school nurse take care of at once?
A. A telephone call notifying the school nurse that the child’ pediatrician has informed the mother
that the child will need cardiac repair surgery within the next few weeks.
B. A telephone call notifying the school nurse that the child’s pediatrician has informed the
mother that the child has head lice.
C. A telephone call notifying the school nurse that a child has a temperature of 102ºF and a rash
covering the trunk and upper extremities of the body.
D. A telephone call notifying the school nurse that a child underwent an emergency
appendectomy during the previous night.
71. Which of the following signs and symptoms that require immediate attention and may indicate
most serious complications during pregnancy?

A. Severe abdominal pain or fluid discharge from the vagina.

B. Excessive saliva, “bumps around the areolae, and increased vaginal mucus.
C. Fatigue, nausea, and urinary frequency at any time during pregnancy.
D. Ankle edema, enlarging varicosities, and heartburn.
72. The nurse is assessing the newborn boy. Apgar scores are 7 and 9. The newborn becomes
slightly cyanotic. What is the initial nursing action?

A. Elevate his head to promote gravity drainage of secretions.

B. Wrap him in another blanket, to reduce heat loss.
C. Stimulate him to cry,, to increase oxygenation.
D. Aspirate his mouth and nose with bulb syringe.
73. The nurse is formulating a plan of care to a client with a somatoform disorder. The nurse needs
to have knowledge of which psychodynamic principle?

A. The symptoms of a somatoform disorder are an attempt to adjust to painful life situations or
to cope with conflicting sexual, aggressive, or dependent feelings.
B. The major fundamental mechanism is regression.
C. The client’s symptoms are imaginary and the suffering is faked.
D. An extensive, prolonged study of the symptoms will be reassuring to the client, who seeks
sympathy, attention and love.
74. An infant is brought to the health care clinic for three immunizations at the same time. The nurse
knows that hepatitis B, DPT, and Haemophilus influenzae type B immunizations should:

A. Be drawn in the same syringe and given in one injection.

B. Be mixed and inject in the same sites.
C. Not be mixed and the nurse must give three injections in three sites.
D. Be mixed and the nurse must give the injection in three sites.
75. A female client with cancer has radium implants. The nurse wants to maintain the implants in the
correct position. The nurse should position the client:

A. Flat in bed.
B. On the side only.
C. With the foot of the bed elevated.
D. With the head elevated 45-degrees (semi-Fowler’s).
76. The nurse wants to know if the mother of a toddler understands the instructions regarding the
administration of syrup of ipecac. Which of the following statement will help the nurse to know that
the mother needs additional teaching?
 A. “I’ll give the medicine if my child gets into some toilet bowl cleaner.”
B. “I’ll give the medicine if my child gets into some aspirin.”
C. “I’ll give the medicine if my child gets into some plant bulbs.”
D. “I’ll give the medicine if my child gets into some vitamin pills.”
77. To assess if the cranial nerve VII of the client was damaged, which changes would not be
expected?

A. Drooling and drooping of the mouth.

B. Inability to open eyelids on operative side.
C. Sagging of the face on the operative side.
D. Inability to close eyelid on operative side.
78. The community health nurse makes a home visit to a family. During the visit, the nurse observes
that the mother is beating her child. What is the priority nursing intervention in this situation?

A. Assess the child’s injuries.

B. Report the incident to protective agencies.
C. Refer the family to appropriate support group.
D. Assist the family to identify stressors and use of other coping mechanisms to prevent further
incidents.
79. The nurse in the neonatal care unit is supervising the actions of a certified nursing assistant in
giving care to the newborns. The nursing assistant mistakenly gives a formula feeding to a newborn
that is on water feeding only. The nurse is responsible for the mistake of the nursing assistant:

A. Always, as a representative of the institution.

B. Always, because nurses who supervise less-trained individuals are responsible for their
mistakes.
C. If the nurse failed to determine whether the nursing assistant was competent to take care of
the client.
D. Only if the nurse agreed that the newborn could be fed formula.
80. The nurse is assigned to care for a client with urinary calculi. Fluid intake of 2L/day is encouraged
to the client. the primary reason for this is to:

A. Reduce the size of existing stones.

B. Prevent crystalline irritation to the ureter.
C. Reduce the size of existing stones
D. Increase the hydrostatic pressure in the urinary tract.
81. The nurse is counseling a couple in their mid 30’s who have been unable to conceive for about 6
months. They are concerned that one or both of them may be infertile. What is the best advice the
nurse could give to the couple?

A. “it is no unusual to take 6-12 months to get pregnant, especially when the partners are in their
mid-30s. Eat well, exercise, and avoid stress.”
B. “Start planning adoption. Many couples get pregnant when they are trying to adopt.”
C. “Consult a fertility specialist and start testing before you get any older.”
D. “Have sex as often as you can, especially around the time of ovulation, to increase your
chances of pregnancy.”
82. The nurse is caring for a cient who Is a retired nurse. A 24-hour urine collection for Creatinine
clearance is to be done. The client tells the nurse, “I can’t remember what this test is for.” The best
response by the nurse is:
 A. “It provides a way to see if you are passing any protein in your urine.”
B. “It tells how well the kidneys filter wastes from the blood.”
C. “It tells if your renal insufficiency has affected your heart.”
D. “The test measures the number of particles the kidney filters.”
83. The nurse observes the female client in the psychiatric ward that she is having a hard time
sleeping at night. The nurse asks the client about it and the client says, “I can’t sleep at night
because of fear of dying.” What is the best initial nursing response?

A. “It must be frightening for you to feel that way. Tell me more about it.”
B. “Don’t worry, you won’t die. You are just here for some test.”
C. “Why are you afraid of dying?”
D. “Try to sleep. You need the rest before tomorrow’s test.”
84. In the hospital lobby, the registered nurse overhears a two staff members discussing about the
health condition of her client. What would be the appropriate action for the registered nurse to take?

A. Join in the conversation, giving her input about the case.

B. Ignore them, because they have the right to discuss anything they want to.
C. Tell them it is not appropriate to discuss such things.
D. Report this incident to the nursing supervisor.
85. The client has had a right-sided cerebrovascular accident. In transferring the client from the
wheelchair to bed, in what position should a client be placed to facilitate safe transfer?

A. Weakened (L) side of the cient next to bed.

B. Weakened (R) side of the client next to bed.
C. Weakened (L) side of the client away from bed.
D. Weakened (R) side of the cient away from bed.
86. The child client has undergone hip surgery and is in a spica cast. Which of the following toy
should be avoided to be in the child’s bed?

A. A toy gun.
B. A stuffed animal.
C. A ball.
D. Legos.
87. The LPN/LVN asks the registered nurse why oxytocin (Pitocin), 10 units (IV or IM) must be given
to a client after birth fo the fetus. The nurse is correct to explain that oxytocin:

A. Minimizes discomfort from “afterpains.”

B. Suppresses lactation.
C. Promotes lactation.
D. Maintains uterine tone.
88. The nurse in the nursing care unit is aware that one of the medical staff displays unlikely
behaviors like confusion, agitation, lethargy and unkempt appearance. This behavior has been
reported to the nurse manager several times, but no changes observed. The nurse should:

A. Continue to report observations of unusual behavior until the problem is resolved.

B. Consider that the obligation to protect the patient from harm has been met by the prior
reports and do nothing further.
C. Discuss the situation with friends who are also nurses to get ideas .
D. Approach the partner of this medical staff member with these concerns.
89. The physician ordered tetracycline PO qid to a child client who weights 20kg. The recommended
PO tetracycline dose is 25-50 mg/kg/day. What is the maximum single dose that can be safely
administered to this child?

A. 1g
B. 500 mg
C. 250 mg
D. 125 mg
90. The nurse is completing an obstetric history of a woman in labor. Which event in the obstetric
history will help the nurse suspects dysfunctional labor in the current pregnancy?

A. Total time of ruptured membranes was 24 hours with the second birth.
B. First labor lasting 24 hours.
C. Uterine fibroid noted at time of cesarean delivery.
D. Second birth by cesarean for face presentation.
91. The nurse is planning to talk to the client with an antisocial personality disorder. What would be
the most therapeutic approach?

A. Provide external controls.

B. Reinforce the client’s self-concept.
C. Give the client opportunities to test reality.
D. Gratify the client’s inner needs.
92. The nurse is teaching a group of women about fertility awareness, the nurse should emphasize
that basal body temperature:

A. Can be done with a mercury thermometer but no a digital one.

B. The average temperature taken each morning.
C. Should be recorded each morning before any activity.
D. Has a lower degree of accuracy in predicting ovulation than the cervical mucus test.
93. The nursing applicant has given the chance to ask questions during a job interview at a local
hospital. What should be the most important question to ask that can increase chances of securing a
job offer?

A. Begin with questions about client care assignments, advancement opportunities, and
continuing education.
B. Decline to ask questions, because that is the responsibility of the interviewer.
C. Ask as many questions about the facility as possible.
D. Clarify information regarding salary, benefits, and working hours first, because this will help in
deciding whether or not to take the job.
94. The nurse advised the pregnant woman that smoking and alcohol should be avoided during
pregnancy. The nurse takes into account that the developing fetus is most vulnerable to environment
teratogens that cause malformation during:

A. The entire pregnancy.

B. The third trimester.
C. The first trimester.
D. The second trimester.
95. A male client tells the nurse that there is a big bug in his bed. The most therapeutic nursing
response would be:
 A. Silence.
B. “Where’s the bug? I’ll kill it for you.”
C. “I don’t see a bug in your bed, but you seem afraid.”
D. “You must be seeing things.”
96. A pregnant client in late pregnancy is complaining of groin pain that seems worse on the right
side. Which of the following is the most likely cause of it?

A. Beginning of labor.
B. Bladder infection.
C. Constipation.
D. Tension on the round ligament.
97. The nurse is conducting a lecture to a group of volunteer nurses. The nurse is correct in
imparting the idea that the Good Samaritan law protects the nurse from a suit for malpractice when:

A. The nurse stops to render emergency aid and leaves before the ambulance arrives.
B. The nurse acts in an emergency at his or her place of employment.
C. The nurse refuses to stop for an emergency outside of the scope of employment.
D. The nurse is grossly negligent at the scene of an emergency.
98. A woman is hospitalized with mild preeclampsia. The nurse is formulating a plan of care for this
client, which nursing care is least likely to be done?

A. Deep-tendon reflexes once per shift.

B. Vital signs and FHR and rhythm q4h while awake.
C. Absolute bed rest.
D. Daily weight.
99. While feeding a newborn with an unrepaired cardiac defect, the nurse keeps on assessing the
condition of the client. The nurse notes that the newborn’s respiration is 72 breaths per minute. What
would be the initial nursing action?

A. Burp the newborn.

B. Stop the feeding.
C. Continue the feeding.
D. Notify the physician.
100. A client who undergone appendectomy 3 days ago is scheduled for discharge today. The nurse
notes that the client is restless, picking at bedclothes and saying, “I am late on my appointment,”
and calling the nurse by the wrong name. The nurse suspects:

A. Panic reaction.
B. Medication overdose.
C. Toxic reaction to an antibiotic.
D. Delirium tremens.
Answers and Rationales
1. A. The oxytocic effect of Pitocin increases the intensity and durations of contractions;
prolonged contractions will jeopardize the safetyof the fetus and necessitate discontinuing the
drug.
2. B. It is of paramount importance to prevent the client from hurting himself or herself or
others.
3. B. After tonsillectomy, clear, cool liquids should be given. Citrus, carbonated, and hot or cold
liquids should be avoided because they may irritate the throat. Red liquids should be avoided
because they give the appearance of blood if the child vomits. Milk and milk products including
pudding are avoided because they coat the throat, cause the child to clear the throat, and
increase the risk of bleeding.
4. A. Phenylephrine, with frequent and continued use, can cause rebound congestion of mucous
membranes.
5. B. The N 95 respirator is a high-particulate filtration mask that meets the CDC performance
criteria for a tuberculosis respirator.
6. C. The most frequent cause of noncompliance to the treatment of chronic, or open-angle
glaucoma is the miotic effects of pilocarpine. Pupillary constriction impedes normal
accommodation, making night driving difficult and hazardous, reducing the client’s ability to read
for extended periods and making participation in games with fast-moving objects impossible.
7. B. This stops the sucking of air through the tube and prevents the entry of contaminants. In
addition, clamping near the chest wall provides for some stability and may prevent the clamp
from pulling on the chest tube.
8. D. Because umbilical cord’s insertion site is born before the fetal head, the cord may be
compressed by the after-coming head in a breech birth.
9. B. It is important to externalize the anger away from self.
10. D. Development normally proceeds cephalocaudally; so the first major developmental
milestone that the infant achieves is the ability to hold the head up within the first 8-12 weeks of
life. In hypothyroidism, the infant’s muscle tone would be poor and the infant would not be able
to achieve this milestone.
11. D. Get a senior nurse who know s the policies, the client, and the doctor. Generally speaking,
a nurse should not accept telephone orders. However, if it is necessary to take one, follow the
hospital’s policy regarding telephone orders. Failure to followhospital policy could be considered
negligence. In this case, the nurse was new and did not know the hospital’s policy concerning
telephone orders. The nurse was also unfamiliar with the doctor and the client. Therefore the
nurse should not take the order unless a) no one else is available and b) it is an emergency
situation.
12. C. The nurse is obligated to inform the nurse manager about changes in the condition of the
client, which may change the decision made by the nurse manager.
13. A. Perinatal risk factors for the development of Down syndrome include advanced maternal
age, especially with the first pregnancy.
14. B. Assignments should be based on scope of practice and expertise.
15. B. The child who is concurrently taking digoxin and diuretics is at increased risk for digoxin
toxicity due to the loss of potassium. The child and parents should be taught what foods are high
in potassium, and the child should be encouraged to eat a high-potassium diet. In addition, the
child’s serum potassium level should be carefully monitored.
16. A. The responsible for an accurate informed consent is the physician. An exception to this
answer would be a life-threatening emergency, but there are no data to support another
response.
17. D. Asking the client to cough and take a deep breath will help determine if the chest tube is
kinked or if the lungs has reexpanded.
18. B. Every event that exposes a client to harm should be recorded in an incident report, as well
as reported to the appropriate supervisors in order to resolve the current problems and permit
the institution to prevent the problem from happening again.
19. D. One of the earliest signs of digoxin toxicity is Bradycardia. For a toddler, any heart rate that
falls below the norm of about 100-120 bpm would indicate Bradycardia and would necessitate
holding the medication and notifying the physician.
20. B. This option is least threatening.
21. D. In preparing the client for discharge that is receiving prednisone, the nurse should caution
the client to (a) take oral preparations after meals; (b) remember that routine checks of vital
signs, weight, and lab studies are critical; (c) NEVER STOP OR CHANGE THE AMOUNT OF
MEDICATION WITHOUT MEDICAL ADVICE; (d) store the medication in a light-resistant
container.
22. A. Progesterone also reduces smooth muscle motility in the urinary tract and predisposes the
pregnant woman to urinary tract infections. Women should contact their doctors if they exhibit
signs of infection. Kegel exercise will help strengthen the perineal muscles; limiting fluids at
bedtime reduces the possibility of being awakened by the necessity of voiding.
23. B. This is the proper use of anger.
24. C. There are several models of case management, but the commonality is comprehensive
coordination of care to better predict needs of high-risk clients, decrease exacerbations and
continually monitor progress overtime.
25. A. Phenytoin should be infused or injected into larger veins to avoid the discoloration know as
purple glove syndrome; infusing into a smaller vein is not appropriate.
26. C. Serum radioimmunoassay (RIA) is accurate within 7days of conception. This test is specific
for HCG, and accuracy is not compromised by confusion with LH.
27. D. Surgery and anesthesia can increase mucus production. Deep breathing and coughing are
essential to prevent atelectasis and pneumonia in the client’s only remaining lung.
28. B. Newborns can get pneumonia (tachypnea, mild hypoxia, cough, eosinophilia) and
conjunctivitis from Chlamydia.
29. D. The client may perceive this as avoidance, but it is more important to redirect back to the
client, especially in light of the manipulative behavior of drug abusers and adolescents.
30. C. It describes a democratic process in which all members have input in the client’s care.
31. A. Contraction of the milk ducts and let-down reflex occur under the stimulation of oxytocin
released by the posterior pituitary gland.
32. B. In case management, the nurse assumes total responsibility for meeting the needs of the
client during the entire time on duty.
33. A. Smoke inhalation affects gas exchange.
34. C. Sperm deposited during intercourse may remain viable for about 3 days. If ovulation occurs
during this period, conception may result.
35. B. This option shows acceptance (key concept) of this age-typical sleep pattern (that of
waking in the early morning).
36. D. Taking the mother’s pulse while listening to the FHR will differentiate between the maternal
and fetal heart rates and rule out fetal Bradycardia.
37. A. Antihistamines cause pupil dilation and should be avoided with glaucoma.
38. A. This suggests that the level of consciousness is decreasing.
39. D. An advance directive is a form of informed consent, and only a competent adult or the
holder of a durable power of attorney has the right to consent or refuse treatment. If the spouse
does not hold the power of attorney, the decisions of the holder, even if opposed by the spouse,
are enforced.
40. C. Gentle but firm guidance and nonverbal direction is needed to intervene when a client with
schizophrenic symptoms is being disruptive.
41. C. Suctioning is only done for 10 seconds, intermittently, as the catheter is being withdrawn.
42. D. The priority for this client is being able to establish an airway.
43. A. Signs of placental separation include a change in the shape of the uterus from ovoid to
globular.
44. B. This could indicate intracranial bleeding. Alteplase is a thrombolytic enzyme that lyses
thrombi and emboli. Bleeding is an adverse effect. Monitor clotting times and signs of any
gastrointestinal or internal bleeding.
45. D. Because flank incision in nephrectomy is directly below the diaphragm, deep breathing is
painful. Additionally, there is a greater incisional pull each time the person moves than there is
with abdominal surgery. Incisional pain following nephrectomy generally requires analgesics
administration every 3-4 hours for 24-48 hours after surgery. Therefore, turning, coughing and
deep-breathing exercises should be planned to maximize the analgesic effects.
46. B. Under high estrogen levels, during the period surrounding ovulation, the cervical mucus
becomes thin, clear, and elastic (spinnbarkeit), facilitating sperm passage.
47. D. After surgery for a ruptured appendix, the client should be placed in a semi-Fowler’s
position to promote drainage and to prevent possible complications.
48. C. Directing and evaluation of staff is a major responsibility of a nursing manager.
49. A. The recommended procedure for administering eyedrops to any client calls for the drops to
be placed in the middle of the lower conjunctival sac.
50. B. Thirst and restlessness indicate hypovolemia and hypoxemia. Internal bleeding is difficult to
recognized and evaluate because it is not apparent.
51. C. Erythema toxicum is the normal, nonpathological macular newborn rash.
52. D. The family needs to understand what brain death is before talking about organ donation.
They need time to accept the death of their family member. An environment conducive to
discussing an emotional issue is needed.
53. A. Bending from the waist in pregnancy tends to make backache worse.
54. B. Support and limit setting decrease anxiety and provide external control.
55. C. The stoma drainage bag is applied in the operating room. Drainage from the ileostomy
contains secretions that are rich in digestive enzymes and highly irritating to the skin. Protection
of the skin from the effects of these enzymes is begun at once. Skin exposed to these enzymes
even for a short time becomes reddened, painful and excoriated.
56. B. It is the most accurate statement of physiological facts for a 28-day menstrual cycle:
ovulation at day 14, egg life span 24 hours, sperm life span of 72 hours. Fertilization could occur
from sperm deposited before ovulation.
57. C. An advocate role encourage freedom of choice, includes speaking out for the client, and
supports the client’s best interests.
58. A. Abstinence will eliminate any unnecessary pain during intercourse and will reduce the
possibility of transmitting infection to one’s sexual partner.
59. B. Anxiety is generated by group therapy at 9:00 AM. The ritualistic behavioral defense of
hand washing decreases anxiety by avoiding group therapy.
60. D. Denial is a very strong defense mechanism used to allay the emotional effects of
discovering a potential threat. Although denial has been found to be an effective mechanism for
survival in some instances, such as during natural disasters, it may in greater pathology in a
woman with potential breast carcinoma.
61. B. The registered nurse cannot delegate the responsibility for assessment and evaluation of
clients. The status of the client in restraint requires further assessment to determine if there are
additional causes for the behavior.
62. C. The client with chest pain may be having a myocardial infarction, and immediate
assessment and intervention is a priority.
63. B. Is correct because semen analysis requires that a freshly masturbated specimen be
obtained after a rest (abstinence) period of 48-72 hours.
64. C. Betamethasone, a form of cortisone, acts on the fetal lungs to produce surfactant.
65. A. Secretions may have pooled above the tracheostomy cuff. If these are not suctioned before
deflation, the secretions may be aspirated.
66. C. Proper handling of sputum is essential to allay droplet transference of bacilli in the air.
Clients need to be taught to cover their nose and mouth with tissues when sneezing or coughing.
Chemotherapy generally renders the client noninfectious within days to a few weeks, usually
before cultures for tubercle bacilli are negative. Until chemical isolation is established, many
institutions require the client to wear a mask when visitors are in the room or when the nurse is
in attendance. Client should be in a well-ventilated room, without air recirculation, to prevent air
contamination.
67. A. It is best to establish baseline information first.
68. B. Listening is probably the most effective response of the four choices.
69. A. Urine flow is continuous. The pouch has an outlet valve for easy drainage every 3-4 hours.
(the pouch should be changed every 3-5 days, or sooner if the adhesive is loose).
70. C. A high fever accompanied by a body rash could indicate that the child has a communicable
disease and would have exposed other students to the infection. The school nurse would want to
investigate this telephone call immediately so that plans could be instituted to control the spread
of such infection.
71. A. Severe abdominal pain may indicate complications of pregnancy such as abortion, ectopic
pregnancy, or abruption placenta; fluid discharge from the vagina may indicate premature
rupture of the membrane.
72. D. Gentle aspiration of mucus helps maintain a patent airway, required for effective gas
exchange.
73. A. Somatoform disorders provide a way of coping with conflicts.
74. C. Immunization should never be mixed together in a syringe, thus necessitating three
separate injections in three sites. Note: some manufacturers make a premixed combination of
immunization that is safe and effective.
75. A. Clients with radioactive implants should be positioned flat in bed to prevent dislodgement of
the vaginal packing. The client may roll to the side for meals but the upper body should not be
raised more than 20 degrees.
76. A. Syrup of ipecac is not administered when the ingested substances is corrosive in nature.
Toilet bowl cleaners, as a collective whole, are highly corrosive substances. If the ingested
substance “burned” the esophagus going down, it will “burn” the esophagus coming back up
when the child begins to vomit after administration of syrup of ipecac.
77. B. Inability to open eyelids on operative side is seen with cranial nerve III damage.
78. A. Assessment of physical injuries (like bruises, lacerations, bleeding and fractures) is the first
priority.
79. C. The nurse who is supervising others has a legal obligation to determine that they are
competent to perform the assignment, as well as legal obligation to provide adequate
supervision.
80. D. Increasing hydrostatic pressure in the urinary tract will facilitate passage of the calculi.
81. A. Infertility is not diagnosed until atleast 12months of unprotected intercourse has failed to
produce a pregnancy. Older couples will experience a longer time to get pregnant.
82. B. Determining how well the kidneys filter wastes states the purpose of a Creatinine clearance
test.
83. A. Acknowledging a feeling tone is the most therapeutic response and provides a broad
opening for the client to elaborate feelings.
84. C. The behavior should be stopped. The first is to remind the staff that confidentiality maybe
violated.
85. C. With a right-sided cerebrovascular accident the client would have left-sided hemiplegia or
weakness. The client’s good side should be closest to the bed to facilitate the transfer.
86. D. Legos are small plastic building blocks that could easily slip under the child’s cast and lead
to a break in skin integrity and even infection. Pencils, backscratchers, and marbles are some
other narrow or small items that could easily slip under the child’s cast and lead to a break in
skin integrity and infection.
87. D. Oxytocin (Pitocin) is used to maintain uterine tone.
88. B. The submission of reports about incidents that expose clients to harm does not remove the
obligation to report ongoing behavior as long as the risk to the client continues.
89. C. The recommended dosage of tetracycline is 25-50mg/kg/day. If the child weighs 20kg and
the maximum dose is 50mg/kg, this would indicate a total daily dose of 1000mg of tetracycline.
In this case, the child is being given this medication four times a day. Therefore the maximum
single dose that can be given is 250mg (1000 mg of tetracycline divided by four doses.)
90. C. An abnormality in the uterine muscle could reduce the effectiveness of uterine contractions
and lengthen the duration of subsequent labors.
91. A. Personality disorders stem from a weak superego, implying a lack of adequate controls.
92. C. The basal body temperature is the lowest body temperature of a healthy person that is
taken immediately after waking and before getting out of bed. The BBT usually varies from 36.2
ºC to 36.3ºC during menses and for about 5-7 days afterward. About the time of ovulation, a
slight drop in temperature may be seen, after ovulation in concert with the increasing
progesterone levels of the early luteal phase, the BBT rises 0.2-0.4 ºC. This elevation remains
until 2-3 days before menstruation, or if pregnancy has occurred.
93. A. This choice implies concern for client care and self-improvement.
94. C. The first trimester is the period of organogenesis, that is, cell differentiation into the various
organs, tissues, and structures.
95. C. This response does not contradict the client’s perception, is honest, and shows empathy.
96. D. Tension on round ligament occurs because of the erect human posture and pressure
exerted by the growing fetus.
97. D. The Good Samaritan Law does not impose a duty to stop at the scene of an emergency
outside of the scope of employment, therefore nurses who do not stop are not liable for suit.
98. C. Although reducing environment stimuli and activity is necessary for a woman with mild
preeclampsia, she will most probably have bathroom privileges.
99. B.  A normal respiratory rate for a newborn is 30-40 breaths per minute.
100. D. The behavior described is likely to be symptoms of delirium tremens, or alcohol withdrawal
(often unsuspected on a surgical unit.)
 PNLE: Pediatric Nursing Exam

 PRACTICE MODE
 EXAM MODE
 TEXT MODE
Text Mode – Text version of the exam
Situation 1: Raphael, a 6 year’s old prep pupil is seen at the school clinic for growth and development
monitoring (Questions 1-5)
1. Which of the following is characterized the rate of growth during this period?

A. most rapid period of growth

B. a decline in growth rate
C. growth spurt
D. slow uniform growth rate
2. In assessing Raphael’s growth and development, the nurse is guided by principles of growth and
development. Which is not included?

A. All individuals follow cephalo-caudal and proximo-distal

B. Different parts of the body grows at different rate
C. All individual follow standard growth rate
D. Rate and pattern of growth can be modified
3. What type of play will be ideal for Raphael at this period?

A. Make believe
B. Hide and seek
C. Peek-a-boo
D. Building blocks
4. Which of the following information indicate that Raphael is normal for his age?

A. Determine own sense self

B. Develop sense of whether he can trust the world
C. Has the ability to try new things
D. Learn basic skills within his culture
5. Based on Kohlberg’s theory, what is the stage of moral development of Raphael?

A. Punishment-obedience
B. “good boy-Nice girl”
C. naïve instrumental orientation
D. social contact
Situation 2 Baby boy Lacson delivered at 36 weeks gestation weighs 3,400 gm and height of 59 cm
(6-10)
6. Baby boy Lacson’s height is

A. Long
B. Short
 C. Average
D. Too short
7. Growth and development in a child progresses in the following ways EXCEPT

A. From cognitive to psychosexual

B. From trunk to the tip of the extremities
C. From head to toe
D. From general to specific
8. As described by Erikson, the major psychosexual conflict of the above situation is

A. Autonomy vs. Shame and doubt

B. Industry vs. Inferiority
C. Trust vs. mistrust
D. Initiation vs. guilt
9. Which of the following is true about Mongolian Spots?

A. Disappears in about a year

B. Are linked to pathologic conditions
C. Are managed by tropical steroids
D. Are indicative of parental abuse
10. Signs of cold stress that the nurse must be alert when caring for a Newborn is:

A. Hypothermia
B. Decreased activity level
C. Shaking
D. Increased RR
Situation 3 Nursing care after delivery has an important aspect in every stages of delivery
11. After the baby is delivered, the cord was cut between two clamps using a sterile scissors and
blade, then the baby is placed at the:

A. Mother’s breast
B. Mother’s side
C. Give it to the grandmother
D. Baby’s own mat or bed
12. The baby’s mother is RH(-). Which of the following laboratory tests will probably be ordered for
the newborn?

A. Direct Coomb’s
B. Indirect Coomb’s
C. Blood culture
D. Platelet count
13. Hypothermia is common in newborn because of their inability to control heat. The following
would be an appropriate nursing intervention to prevent heat loss except:

A. Place the crib beside the wall

B. Doing Kangaroo care
C. By using mechanical pressure
D. Drying and wrapping the baby
14. The following conditions are caused by cold stress except

A. Hypoglycemia
B. Increase ICP
C. Metabolic acidosis
D. Cerebral palsy
15. During the feto-placental circulation, the shunt between two atria is called

A. Ductus venosous
B. Foramen Magnum
C. Ductus arteriosus
D. Foramen Ovale
16. What would cause the closure of the Foramen ovale after the baby had been delivered?

A. Decreased blood flow

B. Shifting of pressures from right side to the left side of the heart
C. Increased PO2
D. Increased in oxygen saturation
17. Failure of the Foramen Ovale to close will cause what Congenital Heart Disease?

A. Total anomalous Pulmunary Artery

B. Atrial Septal defect
C. Transposition of great arteries
D. Pulmunary Stenosis
Situation 4 Children are vulnerable to some minor health problems or injuries hence the nurse should
be able to teach mothers to give appropriate home care.
18. A mother brought her child to the clinic with nose bleeding. The nurse showed the mother the
most appropriate position for the child which is:

A. Sitting up
B. With low back rest
C. With moderate back rest
D. Lying semi flat
19. A common problem in children is the inflammation of the middle ear. This is related to the
malfunctioning of the:

A. Tympanic membrane
B. Eustachian tube
C. Adenoid
D. Nasopharynx
20. For acute otitis media, the treatment is prompt antibiotic therapy. Delayed treatment may result
in complications of:

A. Tonsillitis
B. Eardrum Problems
C. Brain damage
D. Diabetes mellitus
21. When assessing gross motor development in a 3 year old, which of the following activities would
the nurse expect to finds?

A. Riding a tricycle
B. Hopping on one foot
C. Catching a ball
D. Skipping on alternate foot.
22. When assessing the weight of a 5-month old, which of the following indicates healthy growth?

A. Doubling of birth weight

B. Tripling of birth weight
C. Quadrupling of birth weight
D. Stabilizing of birth weight
23. An appropriate toy for a 4 year old child is:

A. Push-pull toys
B. Card games
C. Doctor and nurse kits
D. Books and Crafts
24. Which of the following statements would the nurse expects a 5-year old boy to say whose pet
gerbil just died

A. “The boogieman got him”

B. “He’s just a bit dead”
C. “Ill be good from now own so I wont die like my gerbil”
D. “Did you hear the joke about…”
25. When assessing the fluid and electrolyte balance in an infant, which of the following would be
important to remember?

A. Infant can concentrate urine at an adult level

B. The metabolic rate of an infant is slower than in adults
C. Infants have more intracellular water that adult do
D. Infant have greater body surface area than adults
26. When assessing a child with aspirin overdose, which of the following will be expected?

A. Metabolic alkalosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Respiratory acidosis
27. Which of the following is not a possible systemic clinical manifestation of severe burns?

A. Growth retardation
B. Hypermetabolism
C. Sepsis
D. Blisters and edema
28. When assessing a family for potential child abuse risks, the nurse would observe for which of the
following?

A. Periodic exposure to stress

 B. Low socio-economic status
C. High level of self esteem
D. Problematic pregnancies
29. Which of the following is a possible indicator of Munchausen syndrome by proxy type of child
abuse?

A. Bruises found at odd locations, with different stages of healing

B. STD’s and genital discharges
C. Unexplained symptoms of diarrhea, vomiting and apnea with no organic basis
D. Constant hunger and poor hygiene
30. Which of the following is an inappropriate interventions when caring for a child with HIV?

A. Teaching family about disease transmission

B. Offering large amount of fresh fruits and vegetables
C. Encouraging child to perform at optimal level
D. Teach proper hand washing technique
Situation 5 Agata, 2 years old is rushed to the ER due to cyanosis precipitated by crying. Her mother
observed that after playing she gets tired. She was diagnosed with Tetralogy of Fallot.
31. The goal of nursing care fro Agata is to:

A. Prevent infection
B. Promote normal growth and development
C. Decrease hypoxic spells
D. Hydrate adequately
32. The immediate nursing intervention for cyanosis of Agata is:

A. Call up the pediatrician

B. Place her in knee chest position
C. Administer oxygen inhalation
D. Transfer her to the PICU
33. Agata was scheduled for a palliative surgery, which creates anastomosis of the subclavian artery
to the pulmonary artery. This procedure is:

A. Waterston-Cooley
B. Raskkind Procedure
C. Coronary artery bypass
D. Blalock-Taussig
34. Which of the following is not an indicator that Agata experiences separation anxiety brought
about her hospitalization?

A. Friendly with the nurse

B. Prolonged loud crying, consoled only by mother
C. Occasional temper tantrums and always says NO
D. Repeatedly verbalizes desire to go home
35. When Agata was brought to the OR, her parents where crying. What would be the most
appropriate nursing diagnosis?

A. Infective family coping r/t situational crisis

 B. Anxiety r/t powerlessness
C. Fear r/t uncertain prognosis
D. Anticipatory grieving r/t gravity of child’s physical status
36. Which of the following respiratory condition is always considered a medical emergency?

A. Laryngeotracheobronchitis (LTB)
B. Epiglottitis
C. Asthma
D. Cystic Fibrosis
37. Which of the following statements by the family of a child with asthma indicates a need for
additional teaching?

A. “We need to identify what things triggers his attacks”

B. “He is to use bronchodilator inhaler before steroid inhaler”
C. “We’ll make sure he avoids exercise to prevent asthma attacks”
D. “he should increase his fluid intake regularly to thin secretions”
38. Which of the following would require careful monitoring in the child with ADHD who is receiving
Methylphenidate (Ritalin)?

A. Dental health
B. Mouth dryness
C. Height and weight
D. Excessive appetite
Situation 6 Laura is assigned as the Team Leader during the immunization day at the RHU
39. What program for the DOH is launched at 1976 in cooperation with WHO and UNICEF to reduce
morbidity and mortality among infants caused by immunizable disease?

A. Patak day
B. Immunization day on Wednesday
C. Expanded program on immunization
D. Bakuna ng kabtaan
40. One important principle of the immunization program is based on?

A. Statistical occurrence
B. Epidemiologic situation
C. Cold chain management
D. Surveillance study
41. The main element of immunization program is one of the following?

A. Information, education and communication

B. Assessment and evaluation of the program
C. Research studies
D. Target setting
42. What does herd immunity means?

A. Interruption of transmission
B. All to be vaccinated
C. Selected group for vaccination
 D. Shorter incubation
43. Measles vaccine can be given simultaneously. What is the combined vaccine to be given to
children starting at 15 months?

A. MCG
B. MMR
C. BCG
D. BBR
Situation 7: Braguda brought her 5-month old daughter in the nearest RHU because her baby sleeps
most of the time, with decreased appetite, has colds and fever for more than a week. The physician
diagnosed pneumonia.
44. Based on this data given by Braguda, you can classify Braguda’s daughter to have:

A. Pneumonia: cough and colds

B. Severe pneumonia
C. Very severe pneumonia
D. Pneumonia moderate
45. For a 3-month old child to be classified to have Pneumonia (not severe), you would expect to find
RR of:

A. 60 bpm
B. 40 bpm
C. 70 bpm
D. 50 pbm
46. You asked Braguda if her baby received all vaccines under EPI. What legal basis is used in
implementing the UN’s goal on Universal Child Immunization?

A. PD no. 996
B. PD no. 6
C. PD no. 46
D. RA 9173
47. Braguda asks you about Vitamin A supplementation. You responded that giving Vitamin A starts
when the infant reaches 6 months and the first dose is”

A. 200,000 “IU”
B. 100,000 “IU”
C. 500,000 “IU”
D. 10,000 “IU”
48. As part of CARI program, assessment of the child is your main responsibility. You could ask the
following question to the mother except:

A. “How old is the child?”

B. “IS the child coughing? For how long?”
C. “Did the child have chest indrawing?”
D. “Did the child have fever? For how long?”
49. A newborn’s failure to pass meconium within 24 hours after birth may indicate which of the
following?
 A. Aganglionic Mega colon
B. Celiac disease
C. Intussusception
D. Abdominal wall defect
50. The nurse understands that a good snack for a 2 year old with a diagnosis of acute asthma would
be:

A. Grapes
B. Apple slices
C. A glass of milk
D. A glass of cola
51. Which of the following immunizations would the nurse expect to administer to a child who is HIV
(+) and severely immunocomromised?

A. Varicella
B. Rotavirus
C. MMR
D. IPV
52. When assessing a newborn for developmental dysplasia of the hip, the nurse would expect to
assess which of the following?

A. Symmetrical gluteal folds

B. Trendelemburg sign
C. Ortolani’s sign
D. Characteristic limp
53. While assessing a male neonate whose mother desires him to be circumcised, the nurse observes
that the neonate’s urinary meatus appears to be located on the ventral surface of the penis. The
physician is notified because the nurse would suspect which of the following?

A. Phimosis
B. Hydrocele
C. Epispadias
D. Hypospadias
54. When teaching a group of parents about seat belt use, when would the nurse state that the child
be safely restrained in a regular automobile seatbelt?

A. 30 lb and 30 in
B. 35 lb and 3 y/o
C. 40 lb and 40 in
D. 60 lb and 6 y/o
55. When assessing a newborn with cleft lip, the nurse would be alert which of the following will
most likely be compromised?

A. Sucking ability
B. Respiratory status
C. Locomotion
D. GI function
56. For a child with recurring nephritic syndrome, which of the following areas of potential
disturbances should be a prime consideration when planning ongoing nursing care?
 A. Muscle coordination
B. Sexual maturation
C. Intellectual development
D. Body image
57. An inborn error of metabolism that causes premature destruction of RBC?

A. G6PD
B. Hemocystinuria
C. Phenylketonuria
D. Celiac Disease
58. Which of the following would be a diagnostic test for Phenylketonuria which uses fresh urine
mixed with ferric chloride?

A. Guthrie Test
B. Phenestix test
C. Beutler’s test
D. Coomb’s test
59. Dietary restriction in a child who has Hemocystenuria will include which of the following amino
acid?

A. Lysine
B. Methionine
C. Isolensine tryptophase
D. Valine
60. A milk formula that you can suggest for a child with Galactosemia:

A. Lofenalac
B. Lactum
C. Neutramigen
D. Sustagen
Answers and Rationales
1. B. a decline in growth rate.   During the Preschooler stage growth is very minimal. Weight gain
is only 4.5lbs (2kgs) per year and Height is 3.5in (6-8cm) per year.
 Review:
 Most rapid growth and development- Infancy
 Slow growth- Toddler hood and Preschooler
 Slower growth- School age
 Rapid growth- Adolescence
2. D. Rate and pattern of growth can be modified. Growth and development occurs in cephalo-
caudal meaning development occurs through out the body’s axis. Example: the child must be
able to lift the head before he is able to lift his chest. Proximo-distal is development that
progresses from center of the body to the extremities. Example: a child first develops arm
movement before fine-finger movement. Different parts of the body grows at different range
because some body tissue mature faster than the other such as the neurologic tissues peaks its
growth during the first years of life while the genital tissue doesn’t till puberty. Also G&D is
predictable in the sequence which a child normally precedes such as motor skills and behavior.
Lastly G&D can never be modified .
3. A. Make believe. Make believe is most appropriate because it enhances the imitative play and
imagination of the preschooler. C and D are for infants while letter A is B is recommended for
schoolers because it enhances competitive play.
4. C. Has the ability to try new things.   Erickson defines the developmental task of a preschool
period is learning Initiative vs. Guilt. Children can initiate motor activities of various sorts on their
own and no longer responds to or imitate the actions of other children or of their parents.  
5. C. naïve instrumental orientation. According to Kohlber, a preschooler is under Pre-
conventional where a child learns about instrumental purpose and exchange, that is they will
something do for another if that that person does something with the child in return. Letter A is
applicable for Toddlers and letter B is for a School age child.
6. A. Long. The average length of full-term babies at birth is 20 in. (51 cm), although the normal
range is 46 cm (18 in.) to 56 cm (22 in.).
7. A. From cognitive to psychosexual. Growth and development occurs in cephalo-caudal (head
to toe), proximo-distal (trunk to tips of the extremities and general to specific, but it doesn’t
occurs in cognitive to psychosexual because they can develop at the same time.
8. C. Trust vs. mistrust. According to Erikson, children 0-18 months are under the developmental
task of Trust vs. Mistrust.
9. A. Disappears in about a year. Mongolian spots are stale grey or bluish patches of
discoloration commonly seen across the sacrum or buttocks due to accumulation of melanocytes
and they disappears in 1 year. They are not linked to steroid use and pathologic conditions.
10. D. Increased RR. Hypothermia is inaccurate cause normally, temperature of a newborn drop,
Also a child under cold stress will kick and cry to increase the metabolic rate thereby increasing
heat so B isn’t a good choice. A newborn doesn’t have the ability to shiver, so letter B and C is
wrong. A newborn will increase its RR because the NB will need more oxygen because of too
much activity.
11. A. Mother’s breast. Place it at the mother’s breast for latch-on. (Note: for NSD breast feed
ASAP while for CS delivery, breast feed after 4 hours)
12. A. Direct Coomb’s. Coomb’s test is the test to determine if RH antibodies are present. Indirect
Coomb’s is done to the mother and Direct Coomb’s is the one don’t to the baby. Blood culture
and Platelet count doesn’t help detect RH antibodies.
13. A. Place the crib beside the wall. Placing the crib beside the wall is inappropriate because it
can provide heat loss by radiation. Doing Kangaroo care or hugging the baby, mechanical
pressure or incubators and drying and wrapping the baby will help conserve heat.
14. B. Increase ICP. Hypoglycemia may occur due to increase metabolic rate, and because of
newborns are born slightly acidic, and they catabolize brownfat which will produce ketones which
is an acid will cause metabolic acidosis. Also a NB with severe hypothermia is in high risk for
kernicterus (too much bilirubin in the brain) can lead to Cerebral palsy. There is no connection in
the increase of ICP with hypothermia. (NOTE: pathognomonic sign of Kernicterus in adult-
asterexis, or involuntary flapping of the hand.)
15. D. Foramen Ovale. Foramen ovale is opening between two atria, Ductus venosus is the shunt
from liver to the inferior vena cava, and your Ductus Arteriosus is the shunt from the pulmonary
artery to the aorta.
16. B. Shifting of pressures from right side to the left side of the heart. During feto-placental
circulation, the pressure in the heart is much higher in the right side, but once breathing/crying
is established, the pressure will shift from the R to the L side, and will facilitate the closure of
Foramen Ovale. (Note: that is why you should position the NB in R side lying position to increase
pressure in the L side of the heart.)
 Review:
 Increase PO2-> closure of ductus arteriosus
  Decreased bloodflow -> closure of the ductus venosus
 Circulation in the lungs is initiated by -> lung expansion and pulmonary
ventilation
 What will sustain 1st breath-> decreased artery pressure
 What will complete circulation-> cutting of the cord
17. B. Atrial Septal defect. Foramen ovale is the opening between two Atria so, if its will not close
Atrial Septal defect can occur.
18. A. Sitting up. The correct position is making the child having an upright sitting position with
the head slightly tilted forward. This position will minimize the amount of blood pressure in nasal
vessels and keep blood moving forward not back into the nasopharynx, which will have the
choking sensation and increase risk of aspiration. Choices b, c, d, are inappropriate cause they
can cause blood to enter the nasopharynx.
19. B. Eustachian tube. This is because children has short, horizontal Eustachian tubes. The
dysfunction in the Eustachian tube enables bacterial invasion of the middle ear and obstructs
drainage of secretions.
20. C. Brain damage. One of the complication of recurring acute otitis media is risk for having
Meningitis, thereby causing possible brain damage. That is why patient must follow a complete
treatment regimen and follow up care. A,B and D are not complications of AOM.
21. A. Riding a tricycle. Answer is A, riding a tricycle is appropriate for a 3 y/o child. Hopping on
one foot can be done by a 4 y/o child, as well as catching and throwing a ball over hand.
Skipping can be done by a 5 y/o.
22. A. Doubling of birth weight. During the first 6 months of life the weight from birth will be
doubled and as soon as the baby reaches 1 year, its birth weight is tripled.
23. C. Doctor and nurse kits. Letter C is appropriate because it will enhance the creativity and
imagination of a pre-school child. Letter B and D are inappropriate because they are too complex
for a 4 y/o. Push-pull toys are recommended for infants.
24. B. “He’s just a bit dead”. A 5 y/o views death in “degrees”, so the child most likely will say that
“he is just a bit dead”. Personification of death like boogeyman occurs in ages 7 to 9 as well as
denying death can if they will be good. Denying death using jokes and attributing life qualities to
death occurs during age 3-5.
25. D. Infant have greater body surface area than adults. Infants have greater body surface area
than adult, increasing their risk to F&E imbalances. Also infants cant concentrate a urine at an
adult level and their metabolic rate, also called water turnover, is 2 to 3 times higher than adult.
Plus more fluids of the infants are at the ECF spaces not in the ICF spaces.
26. C. Metabolic acidosis. Remember that Aspirin is acid (Acetylsalicylic ACID).
27. D. Blisters and edema. The question was asking for a SYSTEMIC clinical manifestation, Letters
A,B and C are systemic manifestations while Blisters and Edema weren’t.
28. D. Problematic pregnancies. Typical factors that may be risk for Child abuse are problematic
pregnancies, chronic exposure to stress not periodic, low level of self esteem not high level. Also
child abuse can happen in all socio-economic status not just on low socio-economic status.
29. C. Unexplained symptoms of diarrhea, vomiting and apnea with no organic basis. Munchausen
syndrome by Proxy is the fabrication or inducement of an illness by one person to another
person, usually mother to child. It is characterized by symptoms such as apnea and siezures,
which may be due to suffocation, drugs or poisoning, vomiting which can be induced with
poisons and diarrhea with the use of laxatives. Letter A can be seen in a Physical abuse, Letter B
for sexual abuse and Letter C is for Physical Neglect.
30. B. Offering large amount of fresh fruits and vegetables. A child with HIV is
immunocompromised. Fresh fruits and vegetables, which may be contaminated with organisms
and pesticides can be harmful, if not fatal to the child, therefore these items should be avoided.
31. C. Decrease hypoxic spells. The correct answer is letter C. Though letter B would be a good
answer too, this goal is too vague and not specific. Nursing interventions will not solely promote
normal G&D unless he will undergo surgical repair. So decreasing Hypoxic Spells is more SMART.
Letter A and D are inappropriate.
32. B. Place her in knee chest position. The immediate intervention would be to place her on
knee-chest or “squatting” position because it traps blood into the lower extremities. Though also
letter C would be a good choice but the question is asking for “Immediate” so letter B is more
appropriate. Letter A and D are incorrect because its normal for a child who have ToF to have
hypoxic or “tets” spells so there is no need to transfer her to the NICU or to alert the
Pediatrician.
33. D. Blalock-Taussig. Blalock-Taussig procedure its just a temporary or palliative surgery which
creates a shunt between the aorta and pulmonary artery so that the blood can leave the aorta
and enter the pulmonary artery and thus oxygenating the lungs and return to the left side of the
heart, then to the aorta then to the body. This procedure also makes use of the subclavian vein
so pulse is not palpable at the right arm. The full repair for ToF is called the Brock procedure.
Raskkind is a palliative surgery for TOGA.
34. A. Friendly with the nurse. Because toddlers views hospitalization is abandonment, separation
anxiety is common. Its has 3 phases: PDD (parang c puff daddy LOL) 1. Protest 2. despair 3.
detachment (or denial). Choices B, C, D are usually seen in a child with separation anxiety
(usually in the protest stage).
 REVIEW:
 Separation anxiety begin at: 9 months
 Peaks: 18 months
35. D. Anticipatory grieving r/t gravity of child’s physical status. In this item letter A and be are
inappropriate response so remove them. The possible answers are C and D. Fear defined as the
perceived threat (real or imagined) that is consciously recognized as danger (NANDA) is
applicable in the situation but its defining characteristics are not applicable. Crying per se can not
be a subjective cue to signify fear, and most of the symptoms of fear in NANDA are physiological.
Anticipatory grieving on the other hand are intellectual and EMOTIONAL responses based on a
potential loss. And remember that procedures like this cannot assure total recovery. So letter D is
a more appropriate Nursing diagnosis.
36. B. Epiglottitis. Acute and sever inflammation of the epiglottis can cause life threatening airway
obstruction, that is why its always treated as a medical emergency. NSG intervention : Prepare
tracheostomy set at bed side. LTB, can also cause airway obstruction but its not an emergency.
Asthma is also not an emergency. CF is a chronic disease, so its not a medical emergency.
37. C. “We’ll make sure he avoids exercise to prevent asthma attacks”. Asthmatic children don’t
have to avoid exercise. They can participate on physical activities as tolerated. Using a
bronchodilator before administering steroids is correct because steroids are just anti-
inflammatory and they don’t have effects on the dilation of the bronchioles. OF course letters A
and B are obviously correct.
38. C. Height and weight. Dental problems are more likely to occur in children under going TCA
therapy. Mouth dryness is a expected side effects of Ritalin since it activates the SNS. Also loss of
appetite is more likely to happen, not increase in appetite. The correct answer is letter C,
because Ritalin can affect the child’s G&D. Intervention: medication “holidays or vacation”. (This
means during weekends or holidays or school vacations, where the child wont be in school, the
drug can be withheld.)
39. C. Expanded program on immunization
40. B. Epidemiologic situation. Letters A, C and D are not included in the principles of EPI.
41. D. Target setting
42. A. Interruption of transmission
43. B. MMR. MMR or Measles, Mumps, Rubella is a vaccine furnished in one vial and is routinely
given in one injection (Sub-Q). It can be given at 15 months but can also be given as early as
12th month.
44. B. Severe pneumonia. For a child aging 2months up to 5 years old can be classified to have
sever pneumonia when he have any of the following danger signs:
 Not able to drink
 Convulsions
 Abnormally sleepy or difficult to wake
 Stridor in calm child or
 Severe under-nutrition
45. D. 50 pbm. A child can be classified to have Pneumonia (not severe) if:
 the young infant is less than 2 months- 60 bpm or more
 if the child is 2 months up to less than 12 months- 50 bpm or more
 if the child is 12 months to 4 y/o- 40 bpm or more
46. B. PD no. 6 Presidential Proclamation no. 6 (April 3, 1986) is the “Implementing a United
Nations goal on Universal Child Immunization by 1990”. PD 996 (September 16, 1976) is
“providing for compulsory basic immunization for infants and children below 8 years of age. PD
no. 46 (September 16, 1992) is the “Reaffirming the commitment of the Philippines to the
universal Child and Mother goal of the World Health Assembly. RA 9173 is of course the “Nursing
act of 2002”
47. B. 100,000 “IU”. An infant aging 6-11 months will be given Vitamin supplementation of 100,
000 IU and for Preschoolers ages 12-83 months 200,000 “IU” will be given.
48. C. “Did the child have chest indrawing?”. The CARI program of the DOH includes the “ASK”
and “LOOK, LISTEN” as part of the assessment of the child who has suspected Pneumonia.
Choices A, B and D are included in the “ASK” assessment while Chest indrawings is included in
the “LOOK, LISTEN” and should not be asked to the mother.
49. A. Aganglionic Mega colon. Failure to pass meconium of Newborn during the first 24 hours of
life may indicate Hirschsprung disease or Congenital Aganglionic Megacolon, an anomaly
resulting in mechanical obstruction due to inadequate motility in an intestinal segment. B, C, and
D are not associated in the failure to pass meconium of the newborn.
50. B. Apple slices. Grapes is in appropriate because of its “balat” that can cause choking. A glass
of milk is not a good snack because it’s the most common cause of Iron-deficiency anemia in
children (milk contains few iron), A glass of cola is also not appropriate cause it contains complex
sugar. (walang kinalaman ang asthma dahil ala naman itong diatery restricted foods na nasa
choices.)
51. D. IPV. IPV or Inactivated polio vaccine does not contain live micro organisms which can be
harmful to an immunocompromised child. Unlike OPV, IPV is administered via IM rout e.
52. C. Ortolani’s sign. Correct answer is Ortolani’s sign; it is the abnormal clicking sound when the
hips are abducted. The sound is produced when the femoral head enters the acetabulum. Letter
A is wrong because its should be “asymmetrical gluteal fold”. Letter B and C are not applicable
for newborns because they are seen in older children.
53. D. Hypospadias. Hypospadias is a c condition in which the urethral opening is located below
the glans penis or anywhere along the ventral surface of the penile shaft. Epispadias, the
urethral meatus is located at the dorsal surface of the penile shaft. (Para di ka malilto, I-
alphabetesize mo Dorsal, (Above) eh mauuna sa Ventral (Below) , Epis mauuna sa Hypo.)
54. C. 40 lb and 40 in. Basta tandaan ang rule of 4! 4 years old, 40 lbs and 40 in.
55. A. Sucking ability. Because of the defect, the child will be unable to form the mouth
adequately arounf the nipple thereby requiring special devices to allow feeding and sucking
 gratification. Respiratory status may be compromised when the child is fed improperly or during
post op period.
56. D. Body image. Because of edema, associated with nephroitic syndrome, potential self concept
and body image disturbance related to changes in appearance and social isolation should be
considered.
57. A. G6PD. G6PD is the premature destruction of RBC when the blood is exposed to
antioxidants, ASA (ano un? Aspirin), legumes and flava beans.
58. B. Phenestix test. Phenestix test is a diagnostic test which uses a fresh urine sample (diapers)
and mixed with ferric chloride. If positive, there will be a presence of green spots at the diapers.
Guthrie test is another test for PKU and is the one that mostly used. The specimen used is the
blood and it tests if CHON is converted to amino acid.
59. B. Methionine. Hemocystenuria is the elevated excretion of the amino acid hemocystiene, and
there is inability to convert the amino acid methionine or cystiene. So dietary restriction of this
amino acids is advised. This disease can lead to mental retardation.
60. C. Neutramigen. Neutramien is suggested for a child with Galactosemia. Lofenalac is
suggested for a child with PKU.