NURSING CARE PRACTICEMANAGEMENT

II
INSTRUCTION: Select the correct answer for each of
the following questions. Mark only the answers for each
item by shading the box corresponding to the letter of
your choice
on the answer sheet provided.
Situation: The community health nurse conducts a
health education class. He reviews the treatment
and diet for nutritional anemia and iron-deficiency
anemia.
1. To prevent nutritional anemia, which of the following
foods are appropriate source of dietary iron?
a. Citrus fruits
b. Fish
c. Green vegetables
d. Milk product
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2. When teaching the parents the proper administration
of liquid oral iron supplements, which of the following
instructions should the nurse emphasize?
a. Stop medication if vomiting occurs
b. Give the supplements with food
c. Decrease dose if constipation occurs
d. Give the medication through a dropper or
straw
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3. For an eight month old infant with severe nutritional
anemia, the best dietary recommendation would be
for the caregiver to:
a. Switch to baby cow milk
b. Delay the introduction of table food in the diet
c. Restrict the amount of milk or formula in the
babys diet to one quart
d. Provide dietary iron sources such us peanuts and
unsweetened chocolates
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4. For a toddler with iron-deficiency anemia, the dietary
consideration the nurse will instruct the family is to
add sources of iron and
a. Vit. D and thiamine
b. Calcium and riboflavin
c. Carbohydrates and vitamins
d. Folic acid and proteins
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5. When teaching the parents of a 7 month old infant
about preventing anemia, the nurse should include
which information
a. Milk is poor source of iron, and infants should
be given solid foods high in iron such as
cereals, vegetables, and meat.
b. Anemia for the duration of infancy is unusual as
infants use fetal iron stores until 18 months of
age.
c. Cows milk is an excellent source of iron, and
infants should be changed from formula to milk as
soon as possible after 6 months of age
d. Anemia can easily occur during infancy and all
infants should receive iron supplements
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SITUATION: The school nurse teaches a group of

pupil how to prevent head lice from spreading.
6. The school nurse explains that lice on a child can be
most easily spread by:
a. Riding in the same jeep or car with someone who
has lice.
b. Standing close to someone who has lice.
c. Sharing bonnets or hats
d. Sitting close to someone who has lice
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7. The school nurse explains that for a family that has
lice infestation, the appropriate instructions for home
care is to:
a. Use commercial anti-lice spray on furniture and
mattresses.
b. Take the childrens clothing and bed linens for dry
cleaning.
c. Immerse combs and brushes in boiling water for
30 minutes to kill lice
d. Soak combs and brushes in Lysol solution of
anti-lice shampoo to kill lice.
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8. The school nurse tells the children that what might
look like dandruff on the hair and scalp but does not
flake off easily is:
a. scabies c. Pediculosis capitus
b. eczema
d. Impetigo
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9. When using an anti-lice shampoo, the school nurse
explains
a. Ample amount shampoo should be used to cover
the hair
b. About 2 oz. of shampoo should be applied to wet
hair
c. Shampoo should be left on the hair for 20 30
minutes before rinsing
d. Hot water should be used for both shampooing
and rinsing
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10.The school informs the children that their parents can
buy over-the-counter treatment for head lice.
a. Neosporin
b. Mafenide (Sulfamylon)
c. Silver sulfadiazine ( silvadene)
d. Permethrin (nix)
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SITUATION: The nurse cares for a newborn
following a normal and spontaneous delivery.
11.When examining the head and the body of the
normal newborn, the nurse would expect to find
which of the following?
a. An open posterior fontanel
b. The head circumference is equal to the chest
measurement
c. 2 to 4 deciduous (baby) teeth erupted
d. The abdominal circumference is approximately 20
inches
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12.The nurse knows that the routing reflex is usually
present at birth in the normal newborn. Which of the

following behaviors is an example of the rooting

reflex? The infant
a. Make sucking noises when lying in the crib
b. Gags when food stimulates the pharynx
c. Abducts arms following a loud noise
d. Turns head to side when the cheek is stroked
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13.The nurse assists with a neurologic exam on the
newborn. The nurse notes that the infant can be lifted
off the examining table when pressure is put on the
palms of the newborns hands. This is an example of
which reflex?
a. Tonic neck reflex
b. Palmar grasp reflex
c. Moro reflex
d. Babinski reflex
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14.The nurse teaches a group of parents with newborns
about skin blemishes. Which of the following
statements by a parent or caregiver would indicate an
understanding of what happens with most skin
blemishes seen in newborns?
a. it is reassuring to hear that those little purple
spots on his face will go away in a few days.
b. I just have to get used to our baby having that
mark that looks like a strawberry.
c. my baby would not have tat mark on his face if
the doctor did not use forceps during the delivery.
d. I am concerned that the yellow color of the skin of
my baby is a sign of a serious disease.
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15.The nurse teaches a group of mothers or caregivers
about control of infection. Which of the following
should the nurse reinforce? The caregiver should:
a. Sterilize any toy the newborn puts into his mouth
at least once a week
b. Encourage the members of the family to hold the
newborn to increase the newborns resistance to
disease.
c. Wash hands frequently especially before
handling the newborn.
d. Check the temperature of the newborn 2 or 3
times a day
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SITUATION: The nurse in a childrens hospital
assists in the care of infants. She reviews the
growth and development of infants.
16.An infant who weighs 7 lbs, 2 oz. at birth would weigh
approximately how many lbs. at 6 mos. of age?
a. 21 lbs
c. 10 lbs
b. 14 lbs
d. 17 lbs
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17.In caring for a 4 month old infant, which of the
following actions by the infant would the nurse note
as appropriate for his age? The infant
a. Grasp an object with two hands
b. Holds a bottle well
c. Tries to pick up an object from the floor
d. Transfers an object from one hand to the other
hand
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18.When assisting with a physical examination on an

infant, the nurse would expect to find the posterior
fontanel closed at what age?
a. 10 months
c. 5 months
b. 8 months d. 3 months
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19.To obtain an accurate heart rate in an infant, which of
the following methods would be the most important
for the nurse to do?
a. count the pulse rate for 30 seconds
b. use a regular stethoscope
c. take an apical pulse
d. check heart rate when infant is quite
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20.In teaching a group of parents with infants, the nurse
would teach that between 6-8 months of age, the
following teeth usually erupt
a. first molars
b. upper lateral incisors
c. lower central incisors
d. cuspid
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SITUATION: The nurse in the community is aware of
prevalence of tuberculosis among the residents.
She conducts home visits and teaches clients
treatment and prevention of tuberculosis.
21.In community health epidemiologic studies, Which of
the following definition of disease prevalence is
correct?
a. The number of individuals affected by a
particular disease at a specific time
b. The proportion of individuals with out the disease
who eventually develop the disease within a
specific period of time
c. The proportion of individuals affected by disease
who live for a particular period of time
d. The rate at which individuals without a specific
disease develops that disease
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22.The nurse explain to the client that tuberculosis is a
communicable disease transmitted by:
a. Using dirty needles
b. Sexual contact
c. Using an infected persons eating utensils
d. Inhaling droplets exhaled from an infected
person
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23.A diagnostic test that is definitive for tuberculosis is:
a. chest x-ray
b. Mantoux text
c. Sputum culture
d. Tuberculin test
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24.Which of the following client is most likely to have
tuberculosis?
a. 55 - year business woman
b. 19-year old college student
c. 45-year old homeless person with a history
alcoholism
d. 40 year old construction worker

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25.The community health nurse assesses a 50 year old
male who claims to have been infected with TB
bacillus some ten years ago but never develop the
disease. The client says he is now being treated for
cancer and is showing signs of TB. The nurse knows
this is type of infection which is:
a. Active infection
b. Primary infection
c. Super infection
d. Tertiary infection
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SITUATION: The nurse in the community teaches
the residents the importance of vaccination. The
nurse emphasizes that that vaccination or
immunization is one of the safest health care
practices.
26.Which of the following statements about vaccines is
correct?
a. three to five doses of live attenuated vaccine are
needed to develop immunity
b. Inactivate does not contain a live organism
and cannot cause disease.
c. Live attenuated vaccines produce disease in most
people
d. Inactivated vaccine can be fatal to an immuno
compromised patient
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27.Which of the following ingredients in the vaccine is
suspected to cause neurodevelopmental disorder?
a. Gelatin
c. Thimerosal
b. Eggs
d. Neomycin
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28.Which statement about vaccine safety is correct?
a. Store all vaccine at room temperature
b. Use soon-to- expire vaccines last
c. Routinely mix different vaccines in the same
syringe
d. Screen for precautions and contraindications
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29.Vaccines can be administered safely to someone:
a. With severe acute illness
b. In shock
c. With a history of anaphylaxis to a vaccine
ingredient
d. With otitis media with or without fever
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30.The nurse understands that people who have a
chronic liver disorder should receive which vaccine?
a. Inactive poliovirus vaccine
b. Hepatitis A virus (HAV)
c. Hepatitis B. Virus
d. Pneumococcal conjugate vaccine
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SITUATION: The nurse in the community provides
health services to individuals, their families, and the
community. The nurse is knowledgeable on the

concepts and principles of primary health care of

PHC .
31.In 1978, the international conference of PHC was
held in Ama Ata, USSR. The global goal
conceptualized was Health for all by the year 2000 by
self-reliance. This means that:
a. nobody will get sick or be disabled anymore
b. health care professionals will provide care for
everybody ion the country or the world for all their
existing ailments
c. Health begins at home, in schools, and in the
workplace.
d. Use of prescription drugs for all ailments
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32.Which of the principles of PHC uses the strategy,
training of the community people in leaderships and
management skills?
a. Social mobilization
b. Decentralization
c. Community participation
d. Self reliance
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33.In PHC, there are eight essential elements to be
emphasized. Which of the elements aims to
persuade people to adopt and sustain healthful life
practices?
a. Essential drugs c. education for HEALTH
b. Nutrition
d. safe water and sanitation
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34.This disease is transmitted through contact of the
skin especially open wounds, moist soil, or vegetation
contaminated with urine of and infected host such as
a rat.
a. Leprosy c. leptospirosis
b. Malaria d. Schistosomiasis
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35.A step in the health care process where SMART
goals or outcome criteria are formulated with the
client
a. Assessment
c. implementation
b. Planning
d. evaluation
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SITUATION: The nurse admits a 25 year old female
patient with Peptic Ulcer. The nurse understands
that safety and comfort for the patient is a nursing
priority
36.The nurse performs hand washing before and after
she cares for the patient. Hand washing is a type of:
a. Surgical asepsis
b. Aseptic technique
c. Medical asepsis
d. Sterile technique
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37.The technique or hand washing is to allow water to
flow from the forearm to the fingertips. Which
principle is observed:
a. From an area of greater contamination to an area
of least contamination.
b. From an area of least contamination to an area
of greater contamination.
c. Wetting facilitates removal of pathogens.

d. Water lowers surface tension and acts as an

emulsifying agent.
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38.When making an occupied bed, which principle is
observed to maintain body mechanics.?
1. Use weight of your body to help pull
the patient
2. Flex the knees when lifting the
patient.
3. Spread your feet to provide a wide
support base
4. Put feet together to provide support
a. 1,2,3 and 4
c. 1,2 and 3
b. 1 and 3
d. 2 and 4
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39.The nurse observes which principle of medical
asepsis.
a. Transfer linens from one patients area to another.
b. Place dirty linens in the hamper.
c. Wash hands after doing a procedure only.
d. Place dirty linens on the floor.
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40.Before making a bed, the nurse arranges the linens
according to use. The purpose is to:
a. Prevent tugging and teasing of linens.
b. Conserve energy and save time.
c. Prevent cross contamination
d. Prevent spread of microorganisms
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SITUATION: The nurse in the nursery units admits
newborn infants for initial care and observation
before the infants are brought to the mother for
rooming-in.
41.The nurse assesses the neonate at 1 and 5 minutes
after delivery using the Agpar scoring system. She
notes that the neonates respiration is slow and
irregular, cardiac time is slow or below 100 bpm;
there is some flexion in the muscle tone; has good
cry; and body is pinkish but extremities are blue. The
finding suggest that the physical condition of the
neonate is:
a. Excellent
c. fair
b. Poor
d. critical
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42.The nurse weights the newborn. She notes a weight
loss of five to ten percent which is normal for the first
few days. She is aware that weight loss should be
43.
44.regained in;
a. 1-3 weeks
b. 2-3 weeks
c. 1-4 weeks
d. 1-2 weeks
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45.The nurse takes the body temperature of the
newborn per axilla and not per rectum. The nurse is
aware that the rectal route is not recommended as
routine for taking body temperature because of:
a. potential for rectal mucosa infection
b. increased risk of perforation
c. potential breakage of rectal thermometer
d. increased risk of rectal bleeding

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46.The nurse observes that the newborn is covered with
grayish, whitish fatty substances of cheesy
consistency. The nurses initial care would be to:
a. bathe the newborn with tepid water.
b. Wrap the newborn with cotton ( not woolen )
blanket.
c. Spread the vernix caseosa over the body
d. Remove the vernix caseosa because it will irritate
the skin of the newborn and cause infection.
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47.The nurse assesses the skin of the newborn and
notes a light distribution of downy fine hair over the
shoulder, forehead and cheeks. The nurse knows
that an extensive amount of lanugo is a sign of:
a. maturity
b. postmaturity
c. infection
d. prematurity
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SITUATION: Baby girl Macsay is delivered vaginally
at 39 weeks gestation. The neonate seems to be in
good physical condition as indicated by an agpar
score of 9 and 10 taken 1 and 5 minutes after
delivery.
48.The nurse when assessing the newborn understands
that:
a. the newborn is making an optimal transition to
extrauterine life.
b. An isolette should be made ready for close
observation of the newborn
c. There is a correlation between a light Agpar score
and intellectual development
d. There is a relationship between a high Agpar
score and normal and emotional development.
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49.The nurse at the nursery for well-babies administers
vitamin K intramuscular to baby Macsay because the:
a. liver of the newborn cannot produce enough
vitamin K
b. newborn is not able to synthesize vitamin K
which is necessary for blood clotting and
coagulation
c. newborn is susceptible to blood clotting disorders
d. fetal red blood cells destroys vitamin K when it
undergoes hemolysis
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50.The nurse drops eye prophylaxis on the eyes of the
newborn, the purpose of which is to:
a. constrict the pupils of the eyes of the newborn to
prevent further injury
b. remove mucus fron the babys eyes
c. prevent infection that might cause blindness
d. prevent neonatal conjunctivitis
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51.While assessing the newborn the nurse observes that
the hands and the feet of the newborn are bluish in
color. The nurse should:
a. massage the hand and feet of the newborn to
restore circulation.
b. Place the newborn in an incubator for at least two
hours

c. Document and report the observation to the

attending physician
d. Wrap the newborn in worm blankets
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52.On further assessment, the nurse observes bluishgray or non-elevated pigmentation area over the
lower back and buttocks of the newborn. The nurse
documents this as:
a. telangiectatics nevi or stroke bites
b. Mongolian spots
c. Nevus vasculosus or strawberry marks
d. Nevus flammerus or port wine marks
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SITUATION: The nurse is caring-for new or first time
mothers in the maternity ward
53.The nurse observes a post partum client who
delivered her first baby 3 days ago to be crying and
feeling low. The nurse should:
a. report the clients behavior to the psychiatrist
b. administer antidepressant drugs
c. let the new mother cuddle her newborn infant
d. give emotional support and let the mother rest
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54.The client on her third post partum day complains of
redness and swelling in both breast. The nurse is
aware that the signs suggest:
a. breast engorgement
b. effects of medication administered
c. infection
d. reaction to the sucking of the infant
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55.For the first1-2 hours, maternal bonding with the
infant should be initiated by the new mother. The
nurse should encourage the mother to:
a. touch the infant and establish eye contact
b. breastfeed the infant
c. bathe the infant with tepid water
d. stimulate the infant to cry
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56.A first time mother who delivered spontaneously per
vagina complains of perineal discomfort when sitting.
The nurse suggest to the mother one of the following
measures to promote comfort.
a. support body weight on the arm of a chair when
seated
b. contract buttocks before sitting or rising from
the chair
c. sit on a pillow
d. place a pillow behind back when sitting
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57.A 20 year old primipara who gave birth vaginally and
spontaneously to an alive baby girl weighing 7 lbs.
the day previously expresses concern that she might
have infection. The nurse explains that two most
important predisposing cause of postpartal infection
area:
a. malnutrition and anemia during pregnancy
b. pre-eclampsia and retention of placenta
c. microorganisms present in the birth canal and
trauma during labor
d. hemorrhage and trauma during labor.

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SITUATION: The nurse in the community utilizes
Community Organizing Participatory Action
Research or COPAR as a tool foe development.
58.Which of the following is not characteristics or
COPAR? COPAR is a:
a. modernization development approach that
assumes that development consists of
abandoning the traditional methods of doing
things and adopting the technology of
industrial countries.
b. Process by which a community identifies its need
s and objectives, develops confidence to take
action in respect to them and in doing so, extends
and develops cooperative attitudes and practices
in the community.
c. Continuous and sustained process of educating
the people to understand and develop their critical
awareness of their existing conditions working
with the people collectively on their immediate
needs toward solving their long-term problems.
d. Social development approach that aims to
transform the apathetic, individualistic and
voiceless poor dynamic, participatory and
politically responsive community.
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59.The focus of COPAR is to:
a. minimize community participation and
involvement/
b. prepare people to eventually take over the
management of a development program or
programs in the future.
c. Empower the rich so they can help the oppressed
sector of the society to pursue a more just and
humane society.
d. Provide resources that are lacking in the
community.
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60.Which of the following is not a process method used
in COPAR
a. consciousness-raising through experiential
learning
b. participatory or mass-based
c. leader-centered
d. progressive cycle of action-reflection-action
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61.it is a critical step or activity in COPAR where the
nurse or community health worker goes around the
community and motivates people on a one to one
basis to do something on the issue that has been
chosen to work on in order to begin organizing the
people.
a. social investigation
b. integration
c. groundwork
d. mobilization
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62.Which of the following functions of a community
nurse or health worker involves helping plan a
comprehensive program with the people.
a. facilitator
b. community health service provider
c. health educator
d. health counselor

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SITUATION: The nurse in a maternal and child clinic
gives instructions and antepartum care to pregnant
clients.
61. A concerned client asks about some marks in her
body she noticed while pregnant. The nurse
explains that the tiny, blanched and slightly raised
end arterioles found on he face, neck, arm, and
chest during pregnancy is called:
a. linea nigra
c. epulis
b. telangiectasis d. striae gravidarum
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62. A pregnant client is concerned about lack of fetal
movement. What instructions would the nurse give
that might offer reassurance?
a. take a worm bath to facilitate fetal movement
b. start taking two prenatal vitamins
c. eat foods that contain high sugar contain to
enhance fetal movement
d. lie down once a day and count the number of
fetal movements for 15 to 30 minutes.
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63. A pregnant client complains of swelling in her feet
and ankles. The most appropriate recommendation
the nurse would suggest is to:
a. buy walking shoes
b. limit fluid intake
c. sit and elevate the feet twice daily
d. start taking a diuretic as needed daily.
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64. The nurse instructs a pregnant client who is in the
later stage of pregnancy to lie on her left side when
resting or sleeping. This is to:
a. facilitate digestion
b. facilitate bladder emptying
c. prevent compression of the vena cava
d. avoid the development of fetal anomalies
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65. A client at 20 weeks gestation visits the clinic for
her first prenatal visit. The nurse takes a fundal
measurement and notes in at 24 cm. Which of the
following is the most likely reason for this abnormal
finding.
a. multiple gestation
b. a large fetus
c. inaccurate date of last menstrual period
d. gestational diabetes
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SITUATION: The nurse assists in the care of pregnant
women admitted in the labor and delivery unit of a
maternity hospital.
66. A woman with uncomplicated pregnancy, full term
and in early labor is admitted. She thinks her water
bag has broken. Which of the following actions by
the nurse would be most appropriate?
a. contact the physician immediately
b. collect a sample of the fluid for microbial
analysis
c. prepare the woman for delivery
d. note the color. Amount, and odor of the fluid.

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67. A 36 weeks pregnant client is admitted to the unit
with mild contractions. Which of the following
complications should the nurse watch for when the
client informs her she has placenta previa.
a. emesis
b. vaginal bleeding
c. fever
d. sudden rupture of membranes
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68. The nurse monitors s client in labor which does not
progress. The physician after ruling out cephalo
pelvic disproportion orders an I.V administration of
1,000 ml normal saline solution with oxytocin
( pitocin ) 10 U to run ay 2 milliunits per minute. The
milliunits per minute is equivalent to how many ml
per minute?
a. 2.0
c. 0.02
b. 0.2
d. 0.002
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69. The nurse monitors a client in labor receiving
oxytocin ( pitocin) to aid her progress. The nurse
observes that a contraction has remained strong for
60 seconds. Which of the following actions should
the nurse take first?
a. notify the physician
b. stop the oxytocin infusion
c. monitor fetal heart tones as usual
d. turn the client on her left side
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70. A woman is admitted in the labor room. During
labor, the amniotic membranes ruptured. Meconium
is present in the amniotic fluid. The nurse knows
that the presence of meconium in the amniotic fluid
is a normal finding in which of the following
situations?
a. prolonged latent phase
b. preterm labor
c. celphalopelvic disproportion
d. breech presentation
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SITUATION: The nurse conducts a mothers class on
the topic breast feeding.
71. The nurse should give further instructions on
breastfeeding to a client who says that she should.
a. wash her breast and nipples with soap and
water before the baby sucks
b. let the infant suck on both breasts at each
feeding
c. wash her breasts and nipples with water only
d. let most of the areola in the mouth of her infant
to ensure proper sucking
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72. A client who has been breastfeeding her infant for
nine days experiences pain, redness and swelling
of her right breast. To promote comfort and relief of
pain, the nurse instructs the woman to:
a. stop breastfeeding for seven days
b. take antibiotics as prescribed by the physician
c. apply warm moist compress over the right
breast
d. wear a loose fitting bra to prevent constriction

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73. The nurse explains the advantage of breastfeeding,
one of which is:
a. its physiologic value
b. breast milk has less immunity to infection
c. breast milk contains optimum nutritional
value for the infant
d. the infant is likely to be allergic to breast milk
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74. The nurse includes in her teaching the importance
of colostrums for the infant which provides the
neonate with:
a. vitamin K which the neonate lacks
b. sufficient iron until more breast milk is produced
c. antibodies that the neonate lacks such as
immunoglobulin A
d. more fat than breast milk
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75. The nurse further instructs the mothers attending
the class to avoid taking any kind of drug while
breastfeeding their infants unless the drugs are
prescribed be the physician. The nurse gives this
instruction because many drugs are known to:
a. Be exerted in the breast milk and affects the
nursing neonate
b. Decrease the quality and quantity of the breast
milk
c. Decrease the motivation of the mother to
breastfeed
d. Interfere with the let-down reflex
_____________________________________________
_____________________________________________
_____________________________________________
SITUATION: Baby boy Soma is delivered at 32 weeks
gestation and weighs only 3 lbs and 6 oz. he is
admitted to the neonatal intensive care unit.
76. The nurse caring for the baby Some places him in
the critical list. Based on the gestational ate and
weight, baby Soma would be classified as:
a. Immature
c. preterm
b. nonviable d.lowbirth-weigth infant
_____________________________________________
_____________________________________________
_____________________________________________
77. The nurse formulates a nursing diagnosis for baby
Soma soon after admission. The priority nursing
diagnosis would be stated as:
a. Altered nutrition related to pre-term gestational
age
b. Impaired gas exchange related to immature
pulmonary vasculature
c. Potential for respiratory distress syndrome
related to prematurity
d. Transient Tachypnea related to immature
respiratory system
_____________________________________________
_____________________________________________
_____________________________________________
78. The nurse feeds baby Soma by gavage. The nurse
is aware that this type of feeding is indicated in
such neonates because:
a. it conserves the strength of the neonate and
does not depend on the swallowing reflex
b. the amount of feed given can be regulated with
accuracy
c. vomiting is prevented
d. feeding can be given quickly thereby minimizing
handling of the neonate

_____________________________________________
_____________________________________________
_____________________________________________
79. The nurse places baby Soma in an incubator to
maintain the infants body temperature at a constant
level. The nurse knows that in such infants, the heat
regulation mechanism is one of the least developed
functions. This is because these infants:
a. perspire a great deal thus losing heat constantly
b. have a surface are that is smaller that normal
newborns
c. lack subcutaneous fat which could provide
some insulation
d. have a limited ability to produce antibodies
against infections
_____________________________________________
_____________________________________________
____________________________________________
80. The mother of baby Soma tells the nurse she wants
to breakfast her infant. The nurse explains that
breast-feeding:
a. is contraindicated because the neonate needs a
high-calorie formula which is given by gavage
every two hours
b. can be done as soon as the neonate is out of
the incubator
c. is not recommended because the neonate
needs more fat than what breast milk contains
d. can be given by gavage feedings until the
neonate has develop a coordinated suchand-swallow reflex
_____________________________________________
_____________________________________________
_____________________________________________
SITUATION: The nurse is assigned to a woman who
had just given birth to a healthy baby boy.
81. When assessing the client after the placenta has
been expressed, the nurse expects the fundus to
be:
a. midway between the symphysis pubis and
the umbilicus
b. at the umbilicus at the upper right quadrant
c. just below the xiphoid process
d. difficult to palpate
_____________________________________________
_____________________________________________
_____________________________________________
82. The nurse observes that the client had chills after
giving birth fifteen minutes ago. The nurse should:
a. assess the amount of blood loss
b. increase the flow of IV fluids
c. cover the client with a warm blanket
d. take the body temperature
_____________________________________________
_____________________________________________
_____________________________________________
83. The nurse inspects the perineum of the post partum
client and notes a constant tricking of blood. The
fundus however is firm and contracted. The nurse
should asses the client further for:
a. uterine infection
b. retained placental tissue
c. vaginal tear
d. uterine inversion
_____________________________________________
_____________________________________________
_____________________________________________
84. The client complains of frequent leg cramps during
the postpartum period. The nurse relates this to:
a. Hypercalcemia
c. hyperkalemia
b. Hypocalcemia
d. hypokalemia
_____________________________________________
_____________________________________________
_____________________________________________

85. The nurse explains to the client that she will

experience vaginal discharges or lochia after
delivery. The client understands the explanation
where she says that on the 2nd and 3rd day, the
lochia should be:
a. white c. brown
b. pink
d. dark red in color
_____________________________________________
_____________________________________________
_____________________________________________
SITUATION: A 20-year old G1P0 woman on the first
stage of labor is admitted in the maternity ward.
86. On admission, the nurse on duty performs a
Leopolds maneuver to determine:
a. if the pregnancy is multifetal
b. the gestational age of the fetus
c. the presentation and position of the fetus
d. the intensity of uterine contractions
_____________________________________________
_____________________________________________
_____________________________________________
87. The nurse monitors the fetal heart rate pattern
intermittently every:
a. 30 minutes during the active phase of labor
b. 2 hours in the latent phase
c. Hour during the active phase
d. 15 minutes during the transition phase
_____________________________________________
_____________________________________________
_____________________________________________
88. The obstetrician performs an internal vaginal
examination and determines that the fetus is at 1
station. The finding suggests that the fetus is
located:
a. 1 finger breath above the ischial spines
b. 1 cm below the ischial spines
c. 1 cm above the ischial spines
d. 1 fingerbreath below the ischial spines
_____________________________________________
_____________________________________________
_____________________________________________
89. The nurse instructs the client how to measure the
frequently of uterine contractions which is
determined:
a. by the number of contractions that occur
within a given period of time
b. by the strength of the contraction at its peak
c. from the beginning of one contraction to the end
of the same contraction
d. from the beginning of one contraction to the end
of the next contraction
_____________________________________________
_____________________________________________
_____________________________________________
90. The obstetrician administers lumbar epidural block
when the cervix of the client has dilated to 6 cm. it
is important that the nurse assess the:
a. color of the amniotic fluid
b. level of consciousness
c. frequency and duration of contraction
d. fetal heart rate
_____________________________________________
_____________________________________________
_____________________________________________
SITUATION: The nurse in the out patient department
is assisting clients seeking prenatal care
91. A 19 year old pregnant woman in her first trimester
asks the nurse if it is safe for her to continue to
smoke, drink occasionally and take medications.
The best advice the nurse can give to this client is:
a. she can take drugs that are only prescribed by
the physician
b. she should cut down on cigarettes, alcoholic
beverages and drugs

c. she should absolutely refrain from smoking

and drinking and avoid taking any drugs
d. she should completely avoid smoking, limit
alcohol intake, but can take aspirin when she
badly needs it
_____________________________________________
_____________________________________________
_____________________________________________
92. The nurse assesses the estimated date of
confinement of the client. The fundal height is
above the level of the symphysis. This finding
suggests that pregnancy is:
a. about 20 weeks
b. between 12 and 14 weeks
c. between 15 and 17 weeks
d. about 36 weeks
_____________________________________________
_____________________________________________
_____________________________________________
93. The nurse formulates a potential nursing diagnosis
for a G1P0 18 year old woman who is in her 1st
trimester to:
a. be at risk of complications
b. be in need of pain management
c. have difficulty in coping and adapting to stress
d. be knowledge deficit
_____________________________________________
_____________________________________________
____________________________________________
94. The 18 year old client in her 1st trimester of
pregnancy complains of leg cramps. The nurse
instructs her to :
a. increase her intake of foods rich in calcium
b. decrease intake of fatty and fried foods
c. increase the intake of fluids
d. increase her intake of foods rich in fiber
_____________________________________________
_____________________________________________
_____________________________________________
95. The client further complains of vertigo and a feeling
of lightheadedness. The nurse instructs the client to
do which of the following to relieve the discomfort
a. turn on her right side while lying in bed
b. sit on a chair with arms relaxed on the arm rest
c. turn on her left side while lying in bed
d. lie flat in bed and avoid unnecessary
movements
_____________________________________________
_____________________________________________
_____________________________________________
SITUATION: The nurse in the labor room monitors
the fetal heart rate of a client in labor
96. The nurse is aware that the normal fetal heart rate
between contractions is beats per minute.
a. 100 to 110
c. 90 to 120
b. 130 to 170
d. 120 to 160
_____________________________________________
_____________________________________________
_____________________________________________
97. The nurse is aware that nursing intervention is not
needed in early deceleration, a characteristics of
which is:
a. FHR decreases but not below 100 beats per
minute
b. FHR decreases but not below 120 beats per
minute
c. FHR decreases to 60 beats per minute
d. Occurs during the relaxation phase
_____________________________________________
_____________________________________________
_____________________________________________
98. When assessing the fetal heart rate and the nurse
notes an irregularity, the nurse should:
a. call for help immediately
b. administer supplemental oxygen

c. place the client in a knee-chest position

d. continue to monitor progress of labor
_____________________________________________
_____________________________________________
_____________________________________________
99. The nurse auscultates the abdomen of the client to
determine the location of the fetal heart beat. If the
fetal heart beats is in the right lower quadrant,
which of the following is most likely the presenting
part?
a. Buttocks
c. head
b. Shoulder
d. feet
_____________________________________________
_____________________________________________
_____________________________________________
100. The nurse is aware that when the fetus is delivered,
an Apgar score is taken based on the nurses
assessment of the newborns:
a. heart rate, respiratory effort, reflex irritability and
color
b. heart rate, respiratory effort, muscle tone,
reflex irritability and color
c. heart rate, respiratory effort, temperature , color
and muscle tone
d. heart rate, respiratory effort, muscle tone and
sucking reflex
_____________________________________________
_____________________________________________
_____________________________________________

God give me work till my

life shall end and till my work
is done