NURSING PRACTICE II - CARE OF HEALTHY MOTHER/CHILD

Situation 1 - This is the first postoperative day for patient Elizawho delivered by caesarean section (CS). Nurse Ivy a newly hired staff was assigned to her.

1. Eliza asks the nurse why she has to get up and walk the dayafter surgery. Which of the following is the BEST response of the nurse? Walking hastens _________.

A. Hastens lactation

B. Relieves pain

C. Heals wounds

D. Fast recovery from anesthesia

C. Heals wounds

2. Which laboratory finding should the nurse assess on the patient 24 hours after caesarian section delivery upon doctor's request?

A. Trace 1+ proteinuria

B. Hematocrit 35%

C. White blood cell count 20,000/cu.mm

D. Hemoglobin 7.0 g/dL

D. Hemoglobin 7.0 g/dL

3. Eliza complains of "afterpains". What should be the nurse IMMEDIATE action?

A. Advise her to stop breast-feeding for a day

B. Encourage her to drink more water

C. Assess vital signs and pain level

D. Administer an analgesic STAT

D. Administer an analgesic STAT

4. Eliza is to be discharge 3 days after CS delivery. Which of the following observations of the nurse would cause the delay of her discharge and would warrant notification to the physician?

A. Moderate amount of lochia rubra

B. Fundus is firm at umbilicus

C. Pulse rate of 61 beats/minute taken in 24 hours

D. Five voidings totaling 240 cc in 12 hours

D. Five voidings totaling 240 cc in 12 hours

5. On the third postpartum day, Eliza reports that she has voided five times that morning. What should the nurse INITIALLY do?

A. Insert a Foley catheter

B. Collect the next voiding and measure the urine amount

C. Catheterize the client to check for residual urine

D. Call the physician

C. Catheterize the client to check for residual urine

Situation 2 - Nurses Flor and Imelda are doing research on, "The common errors regarding Standard of Nursing Documentation in the Obstetrics Ward of Medical Center."

6. Which could be the MAJOR Purpose of the study? To __________.

A. Improve the clarity of documentation

B. Duplicate the study in other hospitals

C. Reduce, if not eliminate, errors in documentation

D. Protect the hospital and staff from being sued

A. Improve the clarity of documentation

7. Which of the following could be the BEST Method to gather the research data?

A. Nursing Audit

B. Focus Group Discussion

C. Phenomenological

D. Survey

A. Nursing Audit

8. What is the term used to describe the arrangement of statistical data that exhibits the number of times the values of a variable occurs?

A. Frequency distribution

B. Frequency

C. Skewness

D. Survey

B. Frequency

9. In statistics, what is the definition of percentage? It is __________.

A. Whole population

B. A value on a scale of 100

C. A share of profits

D. Part of a whole expressed in hundredths

D. Part of a whole expressed in hundredths

10. Based from the study's findings, to whom are the study's recommendations generally addressed? Using the situation a forecited, the recommendation should be addressed to _________.

I. Nursing educators

II. Staff nurses

III. Nursing Service Administrators

IV. Hospital Administrators

A. I, II, III

B. I, III, IV

C. C. I, II, III, IV

D. D. II, III, IV

A. I, II, III

Situation 3 - Patient Carlita, 19 years old, is in her first

trimester of pregnancy. Because it is her first pregnancy, she went for her prenatal check-up with her mother. She asked a lot of questions which she expects the nurse to answer her.

11. The nurse asked for the personal data of the patient which, to some, Carlita did not like to answer. And so she asked: "Why do you need to know if I am married?" what should be a good

response of the nurse? "I asked your marital status because ____

D. Your husband is your best support system during your pregnancy."

12. The patient asked what is the term for signs such as breast changes, urinary frequency, fatigue, morning sickness and amenorrhea?

A. Probable signs

B. Presumptive signs

C. Possible signs

D. Positive signs

B. Presumptive signs

13. The patient asked what causes newborn babies with total absence of extremities. The nurse answered that the cause for Amelia is intake of which of the following medications during pregnancy ___________.

A. Anti-emetics

B. Antibiotics

C. Analgesics

D. Anti-bacterials

A. Anti-emetics

14. The patient complained that every morning, she becomes nauseated and oftentimes, she would vomit excessively. "What could be the cause of this," she asked? The nurse's answer is: "It is due to increase level of ________."

A. Heart burn

B. Estrogen

C. heart rate

D. Progesterone

B. Estrogen

15. The nurse advised patient Carlita to report to her physician which of the following MOST important

sign, if ever she will suffer from it?

A. Cough

B. Vaginal bleeding

C. Headache

D. strong fetal movement

B. Vaginal bleeding

Situation 4 - As a newly-hired staff nurse of the hospital, Erlyn learned that the hospitals have an in-service training for its staff. The in-service trainings conducted are based on hospital and staff's needs. One of the identified needs was on knowledge deficit of Mother and Baby Friendly Hospital Initiative (MBFHI).

16. What is the FIRST step among the ten steps for successful breastfeeding?

A. Have a written breastfeeding policy that is routinely communicated to all staff.

B. Inform al

A. Have a written breastfeeding policy that is routinely communicated to all staff.

17. When practicing rooming-in, how long should the baby stay with the mother? ______ hours.

A. 8

B. 24

C. 12

D. 10

B. 24

18. What is the CORRECT time for which the mother should initiate breastfeeding? It should be _______ hours after birth.

A. ½

B. 1

C. 3

D. 2

A. ½

19. Erlyn learned that newborn infants should ONLY be given, which of the following?

A. Fruit juice

B. Breastmilk

C. water

D. cow's milk

B. Breastmilk

20. Which is the LAST part of the initiative, as recommended by WHO and UNICEF, for the MBFHI external team to do before its final designation as MBFHI Hospital?

A. Assess business facilities if they follow the 10 steps for successful breastfeeding.

B. Develop a research on the benefits of breastfeeding within the institution.

C. Disseminate the benefits of breastfeeding to communities.

D. Follow up mothers if they are exclusively breastfeeding.

A. Assess business facilities if they follow the 10 steps for successful breastfeeding.

Situation 5 - Jane is 23 years old. She and her boyfriend, Kevin, are planning to get married in a couple of months. Thereafter, they plan to have three babies. For this reason they sought reproductive health counseling for their benefit and the

proper growth and development of their future children. Nurse Nilda was there to help them.

21. Jane asks what she must do in order to be healthy in case she becomes pregnant. Which among the answers of Nurse Nilda should NOT be followed by Jane?

A.

B. May have a massage from a lay midwife.

22. Kevin asks what possible contribution he could give for the normal development of the baby. Nurse Jane agreed that his BEST contribution would be the following EXCEPT __________.

A. Stroke Jane's abdomen and talk to baby

B. Provide Jane nutritious food and drinks

C. Join wife during prenatal check-up

D. May smoke once in a while

D. May smoke once in a while

23. For the normal developmental of the fetus, Nurse Nilda taught the couple that Jane should prevent Folic Acid Deficiency anemia by good diet, correct way of cooking vegetables and taking Folic Acid supplements. Which of the following is NOT included among the outcomes of folic acid deficiency to the baby?

A. Cleft lip

B. Cleft palate

C. Neural tube defect

D. Fractures of all types

D. Fractures of all types

24. Jane asks the nurse what possible diseases should she avoid that would guarantee health for the baby? These are:

1. Rubella

2. Rheumatic fever

3. Anemia

4. Chronic hypertension

A. 1, 2, 3

B. 1, 2, 3, 4

C. 1, 2, 4

D. 2, 3, 4

B. 1, 2, 3, 4

25. Nurse Nilda advised the couple that the BEST way to check the condition of the mother and the baby is to have _________.

A. Regular well-selected exercise

B. Regular prenatal check-up

C. Music therapy

D. Good food

B. Regular prenatal check-up

Situation 6 - A hospitalized adolescent Robbie suddenly has a seizure while his family is visiting. Nurse Karen notes whole body rigidity followed by general jerking movements. Robbie vomits immediately after seizure.

26. Which of the following would be the PRIORITY nursing diagnosis for Robbie?

A. Fluid volume deficit related to vomiting. Risk for fluid volume deficit

B. Altered family processes related to chronic illness.

C. High risk for infection related to vomiting.

D. Risk for aspir

D. Risk for aspiration related to loss of consciousness

27. Which of the following would be the LEAST PRIORITY nursing care for a child with seizure disorder?

A. Observation and recording all seizures.

B. Ensuring safety and protection from injury.

C. Teaching the family about anticonvulsant drug therapy: indication, dosage, route and effects.

D. Assessing for signs and symptoms of Increased Intracranial Pressure.

D. Assessing for signs and symptoms of Increased Intracranial Pressure.

28. Robbie will be taking phenytoin (Dilantin) regularly for seizure control. Which of the following will be the MOST important teaching to Robbie's family?

A. Administer acetaminophen to promote sleep.

B. Serve a diet that is high in iron

C. Maintain good oral hygiene and dental care

D. Omit medication if the child is seizure free

C. Maintain good oral hygiene and dental care

29. After teaching the parents about their child's unique psychological needs related to a seizures disorder and possible stressors, which of the following concerns voiced by them would indicate the need for additional teaching? The child's

___________.

A. Feeling different from peers

B. Cognitive delays

C. Poor self-image

D. Dependency

B. Cognitive delays

30. Which of the following is NOT a focus for teaching plan for an adolescent with a seizure disorder?

A. Obtaining a driver's license

B. Increase risk for infections

C. Peer pressure

D. Drug and alcohol use

B. Increase risk for infections

Situation 7 - Any pregnancy may pose a risk. A pregnant woman must therefore submit herself for regular pre-natal consultation in any health facility near her place of abode. A nurse can play an important role in making these pregnant

women aware of these risks in all stages of pregnancy.

31. What CHIEF ingredient of the prenatal vitamin for

pregnancy nutrition that the patient should look for?

A. Vitamin B12

B. Potassium

C. Vitamin C

D. Folic Acid.

D. Folic Acid

32. A woman in labor is at risk for abruptio placenta. Which of the following assessments would MOST convince you and the pregnant woman to believe that this has happened?

A. Painless vaginal bleeding and downward trend of BP.

B. And increased blood pressure and scanty urination.

C. Pain at the lower quadrant and increased pulse rate.

D. Sharp fundal pain and discomfort between contractions.

D. Sharp fundal pain and discomfort between contractions.

33. A woman 2 ½ months pregnant calls you by telephone because she passed out some "berry-like" blood clots and now has continued dark brown vaginal bleeding. Which of the following is the BEST instruction you should give her?

A. "Continue normal activity but take your pulse and

respiratory rate every 4 hours."

B. "Come to the health facility if uterine contractions start."

C. "Come to the health facility with any vaginal material passed out."

D. "Maintain bedrest and count the number of

C. "Come to the health facility with any vaginal material passed out."

34. A woman, 33 weeks pregnant, with preterm rupture of membranes had blood work ordered daily. Which laboratory report would be MOST important to read daily?

A. Serum creatinine

B. Red blood cell count

C. Sodium and potassium levels

D. White blood cell count

D. White blood cell count

35. An 18 -year -old delivers to an 8 -pound - baby after 10 hours of labor. In the post-partal period, which of the following would be a PRIORITY concern to assess for by the nurse?

A. Endometritis

B. Thrombophlebitis

C. Bleeding

D. Amniotic embolus

C. Bleeding

Situation 8 - Patient Fe, 15 years old, G0P1, AOG 39 weeks, has been admitted at 6:30 in the morning for lumbo-sacral pains and strong uterine contractions every 10 minutes. Nurse Jocele was there to admit her. She uses Focus, Data, Action and Response (FDAR) as the form of charting.

36. In any type of charting or documentation, which of the following should the nurse refer to and use to generate and describe the status of patient Fe? Nursing __________.

A. Assessment

B. Process

C. actions

A. Assessment

37. Which of the following are the purposes of documentation? To ________.

I. Ensure the development of organized comprehensive care plan

II. Have a clear and accurate record of what was done to the patient.

III. Have an evidence of the health care member's

accountability in giving care

IV. Detect patients who are clinically deteriorating *

A. II, III, IV

B. I, II, III, IV

C. I, II, III

D. I, III, IV

C. I, II, III

38. Which of the following is the CORRECT definition of focus charting?

A. It is an electronically form of documentation of nursing care done to a patient by a registered nurse.

B. It is a note, written or electronically generated, to provide documentation related to a specific focus.

C. It is a nurse-centered way of documentation that describes the patient status and nursing care rendered.

D. It is a nurse-centered approach to documentation

B. It is a note, written or electronically generated, to provide documentation related to a specific focus.

39. In the given situation, which is the FOCUS?

A. Jocele as the admitting nurse

B. Lumbo-sacral pains and strong uterine contractions

C. 15 years old, G0P1, AOG of 36 weeks

D. Admission at 6:30 in the morning

B. Lumbo-sacral pains and strong uterine contractions

40. What is the term used to describe the patient's data or assessment, the action done based on the assessment and response based on the action made:

A. Progress Note

B. Flow sheets

C. Standard of Care

D. Focus Format

D. Focus Format

Situation 9 - Head nurse Carmen supervises Nurse Donna who is assigned to take care of a newborn baby boy named Henrich with a cleft palate.

41. The mother asks the head nurse why the pediatrician recommended that closure of the palate should be done before he is 6 months old. She asked Nurse Donna to answer her. Which of the following is Nurse Donna's APPROPRIATE response?

A. "After age 2, surgery is very frightening and should be avoided if possible."

B. "The eruption of the 2-year molars

C. "Surgery should be performed before the child starts to use faulty speech patterns."

42. The head nurse continued to ask Nurse Donna, "A cleft lip predispose an infant to infections PRIMARILY because of which of the following reasons?"

A. Waste products that accumulate along the defect.

B. Inadequate circulation in the defective area.

C. Deficient nutrition from ineffective feeding.

D. Mouth breathing that dries the oropharyngeal mucous membranes.

D. Mouth breathing that dries the oropharyngeal mucous membranes.

43. Which SIGNIFICANT statement of the mother predisposes her son to cleft lip or palate?

A. "On my 6 months of pregnancy, I saw a rabbit with the same case of my son."

B. "I am asthmatic and I usually take steroids."

C. "My mother- in- law doesn't like me, that's why she cursed me."

D. "I believe my enemy did some forms of witchcraft on me."

B. "I am asthmatic and I usually take steroids."

44. For an infant born with a unilateral cleft lip and palate, which of the following type of feeding will be BEST to use?

A. Rubber-tipped syringe or medicine dropper.

B. Full breast feeding.

C. IV fluids on limited number of ounces.

D. Cross-cut rubber nipple.

D. Cross-cut rubber nipple.

45. Which of the following is the number ONE consideration in the care of an infant after the surgical repair of a cleft lip?

A. Preventing the infant from crying

B. Feeding the infant with a spoon for 2 days after surgery

C. Placing the infant in a semi-sitting position

D. Keeping the infant NPO for 1 say after surgery.

C. Placing the infant in a semi-sitting position

Situation 10 - Miel, on her 35 weeks of gestation, is admitted because of hypertension, BP of 185/110, severe headache and blurred vision. She was placed on imposed bedrest without toilet privileges. The physician orders MgSo4. Erika is the nurse assigned to her.

46. Which of the following would Nurse Erika anticipate in then patient's maternal history?

A. On and off vaginal spotting

B. Esophageal discomfort is experienced after a heavy meal.

C. Weight gain of 20lbs in the 1st and 2nd Trime

C. Weight gain of 20lbs in the 1st and 2nd Trimester

47. When a patient is on an imposed bedrest, which of the following can help the patient cope? These are the following, EXCEPT __________.

A. Let the patient lie on her side to allow more blood to the uterus.

B. Increase fluid intake to 8 glasses a day to prevent

constipation.

C. Discourage participation of family in patient care to prevent further anxiety.

D. Use relaxation techniques to help cope with stress such as music and books.

C. Discourage participation of family in patient care to prevent further anxiety.

48. MgSo4 injections are painful to the patient. Which of the following is the BEST route for injection to prevent such negative experience for patient Miel?

A. Intravenous injection at the main IV line.

B. Intravenous injection given through "piggy back".

C. Intramuscular on each of the deltoid muscle.

D. Deep intramuscular using z-track technique on buttocks

B. Intravenous injection given through "piggy back".

49. The nurse must be alert to MgSo4 toxicity. Which of the following in NOT included?

A. Fetal bradycardia

B. Urine output of <30 ml per hour

C. Respiration of <12 per min

D. Increase in maternal pulse rate

D. Increase in maternal pulse rate

50. Which of the following hospital environment will be MOST conducive to Miel's condition? A room that is / with ____________.

A. Bright and well-ventilated

B. 2 or three other patients

C. Quiet and non-stimulating

D. A call button for watcher's use

C. Quiet and non-stimulating

Situation 11 - Cathlyn is 19 years old, a grade 12 student. She recently confessed to Nurse Patty that she had sexual intercourse with her boyfriend (BF), 18 years old classmate of hers. She believes that she is pregnant because she missed menstruating for 3 months. She also related that her BF has

recently been confined for pneumonia after an on and off flu-like symptoms. She suspects he has HIV because of his "closeness to a guy who has overtly expressed his feelings on him."

51. Cathlyn wa

B. I, II, III

52. Nurse Patty can also explain the purpose of security measures for data protection which is to maintain the availability, integrity and confidentiality of personal data of all patients. Which of the following actions of anybody is against

personal data protection?

I. Unlawful destruction

II. Alteration

III. Disclosure

IV. Unlawful processing.

A. I, II, III

B. II, III, IV

C. I, II, III, IV

D. I, III, IV

C. I, II, III, IV

53. To erase the doubt of Cathlyn as to whether she has been infected with HIV by her BF, what is the BEST advice of the nurse?

A. Wait until you have access to the diagnosis of your BF.

B. Submit herself for Elisa Test considering window period.

C. Wait until the baby is born.

D. Go for Elisa Test immediately

D. Go for Elisa Test immediately

54. In case the personal data of Cathlyn's BF has been accessed accidentally by "somebody", who has the right to file a complaint?

A. Cathlyn's BF

B. The other guy

C. the parents

D. Cathlyn

A. Cathlyn's BF

55. How long should personal data of an HIV patient be stored on laptops or other portable devices which permits his identification? For as long as __________.

A. The patient likes

B. His doctor likes

C. It is needed as part of an international or national research

D. It is necessary for the purpose for which it was collected and processed

D. It is necessary for the purpose for which it was collected and processed

Situation 12 - Mrs. Geminy, 20 years old, visited the prenatal clinic with her husband George. Nurse Connie noted that the fundus is at the level of the umbilicus. Being her first pregnancy, the patient asks the clinic nurse about pregnancy and childbearing.

56. Based from the assessment of the nurse, what would be the estimated age of gestation, in WEEKS, if then fundus is at the level of the umbilicus

A. 8

B. 10

C. 6

D. 12

E. NONE OF THE ABOVE

WALAY ANSWER:(

57. When is the placenta, which is the source of estrogen and progesterone, fully developed? It is on the __________ weeks of pregnancy?

A. 8

B. 20

C. 16

D. 28

B. 20

58. Mrs. Geminy related that she oftentimes feel nauseated in the afternoon. Which of the following should Nurse Connie advise her to do?

A. Eat sky flakes and follow it up with water

B. Drink iced carbonated drinks

C. Drink hot chocolate or coffee

D. Eat frequent but small amount of foods

A. Eat sky flakes and follow it up with water

59. Which of the following periods of pregnancy does

organogenesis occur?

A. Third

B. First

C. Second

D. Fourth

B. First

60. What sign of pregnancy is morning sickness characterized

by nausea?

A. Probable, subjective

B. Presumptive, subjective

C. Probable, objective

D. Presumptive, objective

B. Presumptive, subjective

Situation 13 - A mother in her first trimester of pregnancy is asthmatic and has taken steroids. This resulted to her baby with cleft lip and cleft palate.

61. While assessing a newborn with cleft lip, the nurse should be alerted on which of the following that will MOST likely be compromised?

A. Locomotion

B. Respiratory status

C. GI function

D. Sucking ability

D. Sucking ability

62. What is the MOST APPROPRIATE response of the nurse to the mother's question as to when the child will be ready for a cleft palate repair? Cleft palate repair is usually done _______.

A. When a large-holed feeding bottle is ineffective for his feeding

B. When the child is completely weaned from bottle feeding

C. Prior to the development of speech

D. After the child has been toilet trained

C. Prior to the development of speech

63. Elbow restraints are the choice during the patient's operation. When is the right time to introduce the use of these restraints? It should be during the _________ phase.

A. Pre-operative

B. Rehabilitative

C. intra- operative

D. post- operative

D. post- operative

64. Before bringing the child to the operating room, what condition of the patient needs immediate notification of the surgeon by the nurse that will warrant suspension of surgery?

A. Colic

B. Atopic dermatitis

C. nasopharyngitis

D. eye deviation

C. nasopharyngitis

65. Include in the post-op plan of care is collaboration and referral of the patient with cleft palate to which of the

following APPROPRIATE health care provider?

A. Speech therapist

B. Dentist

C. dietetian

D. gynecologist

A. Speech therapist

Situation 14 - The giving of medication to a pediatric patient is a serious responsibility of a nurse. The need for accuracy in giving medication is greater than with adult patients. Nurse mimi has just been assigned to the Pediatric Wards. 66. Dosage, when giving medicine to pediatric patients, varies

according to which of the following? Select all that apply

1. Size

2. Surface area

3. Age of child

4. Height

A. 3 only

B. 1 and 2

C. 1, 2, 3

D. 1, 2, 3, 4

D. 1, 2, 3, 4

67. Nurse Mimi is being reviewed by her Headnurse onadministering oral medication on pediatric patients. Which ofthe following statements below is CORRECT?

A. The child should be told to place the tablet in the middle ofbhis tongue and to drink water, fruit juice, milk in order to wash down the tablet.

B. A child's reaction to a dose ordered by a physician is not less predictable than adult's reaction.

C. When giving oral medication, the child as young as two years of age CANNOT be taught to sw

D. The possibility of error is greater in the giving of medication to children than to adults

68. In children and infants, which part is often used for intramuscular injection to reduce the risk of vascular and peripheral nerve (sciatic) injuries?

A. Deltoid muscle

B. Gluteus maximus

C. Dorsogluteal

D. Vastus lateralis

D. Vastus lateralis

69. Comprehensive surveys of research reports and case study literature about intramuscular injections revealed that administering medication intramuscularly can produce a variety of serious adverse effects. When asked by the Headnurse what possible complications can arise, Nurse Mimi should include which of the following?

1. Skin and tissue trauma

2. Muscle fibrosis and contracture

3. Nerve palsies and paralysis

4. Infectious processes such as abscesses or gangrene

A. 1, 3, and 4

B. 1,

B. 1, 2, 3, 4

70. Prior to administering the drugs ordered by the

Pediatrician, Nurse Mimi needs to know if she is giving the ordered medication to the right patient. The FIRST step is __________.

A. Check patient's identification bracelet.

B. Compare medication to order to identification bracelet and patient's stated name and birth date.

C. Verify patient's allergies with chart and with patient.

D. Ask patient to state their name and birth date

B. Compare medication to order to identification bracelet and patient's stated name and birth date

Situation 15 - Karen, 5 years of age, is admitted to the

Pediatric Ward due to severe otalgia, fever and irritability. The mother informed Nurse Ramona, who is assigned to Karen, that patient had upper respiratory infection three weeks prior

to admission. The admission diagnosis is acute otitis media

(AOM).

71. Nurse Romana makes her INITIAL assessment on Karen. The patient keeps on crying and constantly pulls her right ear. What is her MOST APPROPRIATE action?

A. Assess the description a

C. Request parent to carry the child

72. Nurse Romana is preparing to administer ofloxacin eardrop on Karen per Doctor's order. She needs to hold the bottle with her hands to warm up the solution to prevent dizziness for _________.

A. 10 minutes

B. 5 minutes

C. 3-5 minutes

D. 1 to 2 minutes

D. 1 to 2 minutes

73. After washing her hands and gently cleaning any discharge that can be removed easily from the outer ear, Nurse Romana positions the child. Which of the following steps follows?

A. Gently press the tragus of the ear four times in a pumping

motion.

B. Drop the medicine into the ear canal.

C. Gently pull the outer ear

D. Keep the up for five minutes

C. Gently pull the outer ear

74.Based on her knowledge on otitis media, Nurse Romana recalls that children are predisposed to AOM due to their Eustachian tubes being, which of the following? Select all that apply.

1. Shorter

2. More horizontal

3. More prone to obstruction by enlarge adenoids

4. Longer

A. 1, 2, 4

B. 1 and 3

C. 3 and 4

D. 1, 2 and 3

D. 1, 2 and 3

75. To promote drainage and reduce pressure from fluid, Nurse Romana's nursing intervention is to have the child assume any of the following positions, EXCEPT:

A. Have the child sit up

B. Put the pillows behind the head

C. Lie on the non-affected area

D. Lie on the affected ear

C. Lie on the non-affected area

Situation 16 - Paraluman, 16 years of age, has been ordered to be discharged. Nurse Nenet is faced with a dilemma as Paraluman refuse to be discharge.

76. Which of the moral problems is nurse Nenet faced with?

A. Ethical sensitivity

B. Ethical responsiveness

C. Ethical valuing

D. Ethical reasoning

D. Ethical reasoning

77. Which of the following are the rights and responsibilities of Nurse Nenet's client while confined in the hospital?

A. Code of Ethics

B. Bioethical Ethics

C. Hospital Client Advocacy

D. Patient's Bill of Rights

D. Patient's Bill of Rights

78. Which of the following principles of bioethics is referred to when Nurse Nenet provides information and supports her client and family in making a decision? *

A. Fidelity

B. Nonmaleficense

C. Justice

D. Autonomy

C. Justice

79. When Nurse Nenet values client advocacy, she follows which of the following guidelines?

A. She is more loyal to the hospital than to her client.

B. She chooses the client's well-being over client's autonomy.

C. She gives priority to the good of the individual client rather than to the good of society in general.

D. She makes decisions for her clients who are not aware of their rights and privileges

C. She gives priority to the good of the individual client rather

than to the good of society in general

80. Which of the following actions best describe the use of the professional value of altruism?

A. Protects the privacy of client regarding the client's health condition.

B. Demonstrates an understanding of the culture of her client.

C. Lobbies for universal access to healthcare.

D. Becomes a mentor to her novice nurses.

B. Demonstrates an understanding of the culture of her client.

Situation 17 - Miss Kat an OB Nurse Specialists, was invited in a forum. The topic was about HIV-AIDS and the group was composed of ten pregnant women, and five newly married women whose husbands are seafarers.

81. Miss Kat's first topic was on HIV transmission. After

explaining the different transmission modes, she asked the group: "Which among the following is the MAJOR mode of transmission of the disease?"

A. Blood Transfusion

B. Needle pricks

C. Sexual intercourse

D. Kissing

C. Sexual intercourse

82. One of the pregnant women asked the BEST way to prevent HIV transmission from a pregnant HIV (+) mother to child?

A. Deliver the child via normal delivery with cervical support

B. Stop pregnancy by abortion

C. Drink antiviral medicines as prescribed by physician

D. Prenatal check-up more than the standards

C. Drink antiviral medicines as prescribed by physician

83. A 20-year-old newly-wed woman, whose husband has recently been diagnosed with HIV, asked: "Will my baby have HIV too?" What is the BEST answer that Miss Kat should give the client?

A. "No, definitely not because your child has not been exposed to any type of HIV transmission."

B. "Yes, because HIV is definitely transmitted to the child form the mother through the placenta.

C. "One way of transmitting HIV from the mother to the baby is through the placenta. However, your child may or may

D. "It depends on the viral load of the mother and many other factors. Let us just see you after you give birth."

84. Miss Kat continued with her health teaching. This time she describes four main routes of HIV transmission. Which one is NOT included?

A. Childbirth and breastfeeding

B. Unprotected vaginal and anal or oral sex

C. Breathing the same air as someone living with HIV does

D. Sharing unsterilized injecting drug equipment.

C. Breathing the same air as someone living with HIV does

85. Miss Kat gave a few questions to her audience about HIV transmission to find out if they were able to learn about it. "Which of the following is the LEAST among HIV transmission that can directly enter the body via the blood stream or mucous

membranes?" This can be through the ___________.

A. Urethra or inside the foreskin of the penis

B. Lining of the vagina, cervix or womb

C. Dermis of the skin rule

D. Lining of the anus

C. Dermis of the skin rule

Situation 18 - Anton, 15 years old, has been informed that she is due for discharge. He has an emergency appendectomy. Nurse Mimi give him some discharge instructions.

86. Anton is noted to be very conversant. To make her

discharge instructions clear, Nurse Mimi should emphasize which of the following?

I. Tell Anton that he can clarify or ask questions.

II. Tell him that it is alright to interrupt if he had to ask a question to clarify

III. Advise him to listen, well

IV. Ask for the pres

C. 1, 2 and 3

87. Nurse Mimi's discharge instruction should contain, which of the following?

I. Take home medication, if any.

II. Date to follow up

III. Activity and exercise

IV. Diet

A. 2, 3 and 4

B. 1, 2 and 3

C. all the options

D. 3 and 4

C. all the options

88. To make Nurse Mimi's discharge instructions to be more effective the following strategies should be used, EXCEPT _____________.

A. Treat him as a child.

B. Use simple understandable words

C. Eye to eye contact to show interest on what is being said

D. Ask for feedback

A. Treat him as a child

89. To get feedback on the discharge instructions, which questions should Nurse Mimi ask?

A. Can you repeat to me what my instructions were?

B. If you understood my instructions then you surely be well

C. Did you understand my instructions?

D. Are my instructions clear?

A. Can you repeat to me what my instructions were?

90. The BEST statement of goodbye that Nurse Mimi is _________.

A. "Bye Anton."

B. "Bye Anton. See you again in the hospital."

C. "Bye Anton. I don't want to see you again in the hospital."

D. "Bye Anton. Remember all my instructions. Keep well."

D. "Bye Anton. Remember all my instructions. Keep well."

Situation 19 - Catalina is the new nurse assigned at Fertility Clinic of an OB Specialty Center. She had to review about the female reproductive cycle, menstrual disorders and appropriate management.

91. Catalina thought that one of her activities would be health teaching and counseling. Which of the following statements by the client regarding premenstrual syndrome would need a further explanation?

A. "I will limit my intake of sodas, coffee and tea."

B. "I will make sure that I will eat s

C. "I will stop any physical exercise one week prior to

menstruation to conserve my energy."

92. The nurse read on how to make a nursing diagnosis for premenstrual syndrome. Which of the following is NOT TRUE about premenstrual syndrome?

A. Signs and symptoms of premenstrual period recur in the luteal phase of the menstrual cycle.

B. Signs and symptoms of premenstrual period recur in the luteal phase of the menstrual cycle

C. Symptom-free period occurs in the follicular phase and must include 7 symptom-free days.

D. Symptoms are severe enough to have an impact on work, lifestyle and

E. None of the Above

93. Nurse Catalina read about the nursing management of primary dysmenorrhea. Which of these should Catalina render?

I. Use of cold compress

II. Soft rhythmic rubbing of the abdomen

III. Analgesics as ordered

IV. Antispasmodics as ordered.

A. II, III, IV

B. I, II, III

C. I, III, IV

D. I, II, IV

A. II, III, IV

94. What is the condition wherein menstrual interval is 45-50

days?

A. Metrorrhagia

B. Menorrhagia

C. Dysmenorrhea

D. Oligomenorrhea

D. Oligomenorrhea

95. What is the condition whereby during menstruation, the patient feels lower abdominal pain that radiates to her back down to her thighs?

A. Hypergonadotrophic amenorrhea

B. Secondary dysmenorrhea

C. Hypogonadotrophic amenorrhea

D. Primary dysmenorrhea

D. Primary dysmenorrhea

Situation 20 - Riza, head nurse at the OB-DR Ward, is

planning to have an in-service training for 25 staff nurses. Based from needs assessment, the training will be on Lactation for 3 days.

96. In order to make the activity a success, which of the following resources would be MOST important?

A. Number of speakers

B. Location of venue

C. Number of Participants

D. Budget Allocation

C. Number of Participants

97. Which of the following resources should be MATERIAL/ SUPPLY?

A. Bond Paper

B. Sound system

C. food and drinks

D. tables and chairs

A. Bond Paper

98. Based from the studies, which among the following is the MOST needed resource of nurses in order to attend in-service training programs?

A. Clothes

B. Time

C. Drinks

D. Notebooks

B. Time

99. Evaluation of the training is an important form of feedback in order to improve future offerings. Which of the following should be given MOST emphasis?

A. Taste and amount of food serve.

B. Discipline of participants

C. Convenience of the venue

D. Knowledge and skills gained

D. Knowledge and skills gained

100. When asking mothers to become real models for

demonstrating breastfeeding, the nurse's MOST important responsibility is which of the following?

A. Word of thanks

B. Stipend/honorarium

C. Priority care

D. Free hospitalization

A. Word of thanks