NCLEX

1. A patient tells you that her urine is starting to look discolored. If you believe this change is due to medication, which of the following patients medication does not cause urine discoloration? a. Sulfasalazine b. Levodopa c. Phenolphthalein d. Aspirin 2. You are responsible for reviewing the nursing units refrigerator. If you found the following drug in the refrigerator it should be removed from the refrigerators contents? a. Corgard b. Humulin (injection) c. Urokinase d. Epogen (injection) 3. A 34 year old female has recently been diagnosed with an autoimmune disease. She has also recently discovered that she is pregnant. Which of the following is the only immunoglobulin that will provide protection to the fetus in the womb? a. IgA b. IgD c. IgE d. IgG 4. A second year nursing student has just suffered a needlestick while working with a patient that is positive for AIDS. Which of the following is the most important action that nursing student should take? a. Immediately see a social worker b. Start prophylactic AZT treatment c. Start prophylactic Pentamide treatment d. Seek counseling 5. A thirty five year old male has been an insulin-dependent diabetic for five years and now is unable to urinate. Which of the following would you most likely suspect?

a. Atherosclerosis b. Diabetic nephropathy c. Autonomic neuropathy d. Somatic neuropathy 6. You are taking the history of a 14 year old girl who has a (BMI) of 18. The girl reports inability to eat, induced vomiting and severe constipation. Which of the following would you most likely suspect? a. Multiple sclerosis b. Anorexia nervosa c. Bulimia d. Systemic sclerosis 7. A 24 year old female is admitted to the ER for confusion. This patient has a history of a myeloma diagnosis, constipation, intense abdominal pain, and polyuria. Which of the following would you most likely suspect? a. Diverticulosis b. Hypercalcaemia c. Hypocalcaemia d. Irritable bowel syndrome 8. Rho gam is most often used to treat____ mothers that have a ____ infant. a. RH positive, RH positive b. RH positive, RH negative c. RH negative, RH positive d. RH negative, RH negative 9. A new mother has some questions about (PKU). Which of the following statements made by a nurse is not correct regarding PKU? a. A Guthrie test can check the necessary lab values. b. The urine has a high concentration of phenylpyruvic acid c. Mental deficits are often present with PKU. d. The effects of PKU are reversible. 10. A patient has taken an overdose of aspirin. Which of the following should a nurse most closely monitor for during acute management of this patient?

a. Onset of pulmonary edema b. Metabolic alkalosis c. Respiratory alkalosis d. Parkinsons disease type symptoms 11. A fifty-year-old blind and deaf patient has been admitted to your floor. As the charge nurse your primary responsibility for this patient is? a. Let others know about the patients deficits b. Communicate with your supervisor your concerns about the patients deficits. c. Continuously update the patient on the social environment. d. Provide a secure environment for the patient. 12. A patient is getting discharged from a SNF facility. The patient has a history of severe COPD and PVD. The patient is primarily concerned about their ability to breath easily. Which of the following would be the best instruction for this patient? a. Deep breathing techniques to increase O2 levels. b. Cough regularly and deeply to clear airway passages. c. Cough following bronchodilator utilization d. Decrease CO2 levels by increase oxygen take output during meals. 13. A nurse is caring for an infant that has recently been diagnosed with a congenital heart defect. Which of the following clinical signs would most likely be present? a. Slow pulse rate b. Weight gain c. Decreased systolic pressure d. Irregular WBC lab values 14. A mother has recently been informed that her child has Downs syndrome. You will be assigned to care for the child at shift change. Which of the following characteristics is not associated with Downs syndrome? a. Simian crease b. Brachycephaly c. Oily skin d. Hypotonicity 15. A patient has recently experienced a (MI) within the last 4 hours. Which of the following medications would most like be administered?

a. Streptokinase b. Atropine c. Acetaminophen d. Coumadin 16. A patient asks a nurse, My doctor recommended I increase my intake of folic acid. What type of foods contain folic acids? a. Green vegetables and liver b. Yellow vegetables and red meat c. Carrots d. Milk 17. A nurse is putting together a presentation on meningitis. Which of the following microorganisms has noted been linked to meningitis in humans? a. S. pneumonia b. H. influenza c. N. meningitis d. Cl. difficile 18.A nurse is administering blood to a patient who has a low hemoglobin count. The patient asks how long to RBCs last in my body? The correct response is. a. The life span of RBC is 45 days. b. The life span of RBC is 60 days. c. The life span of RBC is 90 days. d. The life span of RBC is 120 days. 19. A 65 year old man has been admitted to the hospital for spinal stenosis surgery. When does the discharge training and planning begin for this patient? a. Following surgery b. Upon admit c. Within 48 hours of discharge d. Preoperative discussion 20. A child is 5 years old and has been recently admitted into the hospital. According to Erickson which of the following stages is the child in? a. Trust vs. mistrust b. Initiative vs. guilt

c. Autonomy vs. shame d. Intimacy vs. isolation 22. A young adult is 20 years old and has been recently admitted into the hospital. According to Erickson which of the following stages is the adult in? a. Trust vs. mistrust b. Initiative vs. guilt c. Autonomy vs. shame d. Intimacy vs. isolation 23. A nurse is making rounds taking vital signs. Which of the following vital signs is abnormal? a. 11 year old male 90 b.p.m, 22 resp/min. , 100/70 mm Hg b. 13 year old female 105 b.p.m., 22 resp/min., 105/60 mm Hg c. 5 year old male- 102 b.p.m, 24 resp/min., 90/65 mm Hg d. 6 year old female- 100 b.p.m., 26 resp/min., 90/70mm Hg 24. When you are taking a patients history, she tells you she has been depressed and is dealing with an anxiety disorder. Which of the following medications would the patient most likely be taking? a. Elavil b. Calcitonin c. Pergolide d. Verapamil 25. Which of the following conditions would a nurse not administer erythromycin? a. Campylobacterial infection b. Legionnaires disease c. Pneumonia d. Multiple Sclerosis

MEDICAL SURGICAL NURSING

SITUATION : Arthur, A registered nurse, witnessed an old woman hit by a motorcycle while crossing a train railway. The old woman fell at the railway. Arthur rushed at the scene. 1. As a registered nurse, Arthur knew that the first thing that he will do at the scene is A. Stay with the person, Encourage her to remain still and Immobilize the leg while While waiting for the ambulance. B. Leave the person for a few moments to call for help. C. Reduce the fracture manually. D. Move the person to a safer place. 2. Arthur suspects a hip fracture when he noticed that the old womans leg is A. Lengthened, Abducted and Internally Rotated. B. Shortened, Abducted and Externally Rotated. C. Shortened, Adducted and Internally Rotated. D. Shortened, Adducted and Externally Rotated. 3. The old woman complains of pain. John noticed that the knee is reddened, warm to touch and swollen. John interprets that this signs and symptoms are likely related to A. Infection B. Thrombophlebitis C. Inflammation D. Degenerative disease 4. The old woman told John that she has osteoporosis; Arthur knew that all of the following factors would contribute to osteoporosis except A. Hypothyroidism B. End stage renal disease C. Cushings Disease D. Taking Furosemide and Phenytoin.

5. Martha, The old woman was now Immobilized and brought to the emergency room. The X-ray shows a fractured femur and pelvis. The ER Nurse would carefully monitor Martha for which of the following sign and symptoms? A. Tachycardia and Hypotension B. Fever and Bradycardia C. Bradycardia and Hypertension D. Fever and Hypertension SITUATION: Mr. D. Rojas, An obese 35 year old MS Professor of OLFU Lagro is admitted due to pain in his weight bearing joint. The diagnosis was Osteoarthritis. 6. As a nurse, you instructed Mr. Rojas how to use a cane. Mr. Rojas has a weakness on his right leg due to self immobilization and guarding. You plan to teach Mr. Rojas to hold the cane A. On his left hand, because his right side is weak. B. On his left hand, because of reciprocal motion. C. On his right hand, to support the right leg. D. On his right hand, because only his right leg is weak. 7. You also told Mr. Rojas to hold the cane A. 1 Inches in front of the foot. B. 3 Inches at the lateral side of the foot. c. 6 Inches at the lateral side of the foot. D. 12 Inches at the lateral side of the foot. 8. Mr. Rojas was discharged and 6 months later, he came back to the emergency room of the hospital because he suffered a mild stroke. The right side of the brain was affected. At the rehabilitative phase of your nursing care, you observe Mr. Rojas use a cane and you intervene if you see him A. Moves the cane when the right leg is moved. B. Leans on the cane when the right leg swings through. C. keeps the cane 6 Inches out to the side of the right foot. D. Holds the cane on the right side. SITUATION: Alfred, a 40 year old construction worker developed cough, night sweats and fever. He was brought to the nursing unit for diagnostic studies. He told the nurse he did not receive a BCG vaccine during childhood

9. The nurse performs a Mantoux Test. The nurse knows that Mantoux Test is also known as A. PPD B. PDP C. PDD D. DPP 10. The nurse would inject the solution in what route? A. IM B. IV C. ID D. SC 11. The nurse notes that a positive result for Alfred is A. 5 mm wheal B. 5 mm Induration C. 10 mm Wheal D. 10 mm Induration 12. The nurse told Alfred to come back after A. a week B. 48 hours C. 1 day D. 4 days 13. Mang Alfred returns after the Mantoux Test. The test result read POSITIVE. What should be the nurses next action? A. Call the Physician B. Notify the radiology dept. for CXR evaluation C. Isolate the patient D. Order for a sputum exam 14. Why is Mantoux test not routinely done in the Philippines? A. It requires a highly skilled nurse to perform a Mantoux test B. The sputum culture is the gold standard of PTB Diagnosis and it will definitively determine the extent of the cavitary lesions C. Chest X Ray Can diagnose the specific microorganism responsible for the lesions

D. Almost all Filipinos will test positive for Mantoux Test 15. Mang Alfred is now a new TB patient with an active disease. What is his category according to the DOH? A. I B. II C. III D. IV 16. How long is the duration of the maintenance phase of his treatment? A. 2 months B. 3 months C. 4 months D. 5 months 17. Which of the following drugs is UNLIKELY given to Mang Alfred during the maintenance phase? A. Rifampicin B. Isoniazid C. Ethambutol D. Pyridoxine 18. According to the DOH, the most hazardous period for development of clinical disease is during the first A. 6-12 months after B. 3-6 months after C. 1-2 months after D. 2-4 weeks after 19. This is the name of the program of the DOH to control TB in the country A. DOTS B. National Tuberculosis Control Program C. Short Coursed Chemotherapy D. Expanded Program for Immunization 20. Susceptibility for the disease [ TB ] is increased markedly in those with the following condition except

A. 23 Year old athlete with diabetes insipidus B. 23 Year old athlete taking long term Decadron therapy and anabolic steroids C. 23 Year old athlete taking illegal drugs and abusing substances D. Undernourished and Underweight individual who undergone gastrectomy 21. Direct sputum examination and Chest X ray of TB symptomatic is in what level of prevention? A. Primary B. Secondary C. Tertiary D. Quarterly SITUATION: Michiel, A male patient diagnosed with colon cancer was newly put in colostomy. 22. Michiel shows the BEST adaptation with the new colostomy if he shows which of the following? A. Look at the ostomy site B. Participate with the nurse in his daily ostomy care C. Ask for leaflets and contact numbers of ostomy support groups D. Talk about his ostomy openly to the nurse and friends 23. The nurse plans to teach Michiel about colostomy irrigation. As the nurse prepares the materials needed, which of the following item indicates that the nurse needs further instruction? A. Plain NSS / Normal Saline B. K-Y Jelly C. Tap water D. Irrigation sleeve 24. The nurse should insert the colostomy tube for irrigation at approximately A. 1-2 inches B. 3-4 inches C. 6-8 inches D. 12-18 inches 25. The maximum height of irrigation solution for colostomy is

A. 5 inches B. 12 inches C. 18 inches D. 24 inches 26. Which of the following behavior of the client indicates the best initial step in learning to care for his colostomy? A. Ask to defer colostomy care to another individual B. Promises he will begin to listen the next day C. Agrees to look at the colostomy D. States that colostomy care is the function of the nurse while he is in the hospital 27. While irrigating the clients colostomy, Michiel suddenly complains of severe cramping. Initially, the nurse would A. Stop the irrigation by clamping the tube B. Slow down the irrigation C. Tell the client that cramping will subside and is normal D. Notify the physician 28. The next day, the nurse will assess Michiels stoma. The nurse noticed that a prolapsed stoma is evident if she sees which of the following? A. A sunken and hidden stoma B. A dusky and bluish stoma C. A narrow and flattened stoma D. Protruding stoma with swollen appearance 29. Michiel asked the nurse, what foods will help lessen the odor of his colostomy. The nurse best response would be A. Eat eggs B. Eat cucumbers C. Eat beet greens and parsley D. Eat broccoli and spinach 30. The nurse will start to teach Michiel about the techniques for colostomy irrigation. Which of the following should be included in the nurses teaching plan? A. Use 500 ml to 1,000 ml NSS B. Suspend the irrigant 45 cm above the stoma

C. Insert the cone 4 cm in the stoma D. If cramping occurs, slow the irrigation 31. The nurse knew that the normal color of Michiels stoma should be A. Brick Red B. Gray C. Blue D. Pale Pink SITUATION: James, A 27 basketball player sustained inhalation burn that required him to have tracheostomy due to massive upper airway edema. 32. Wilma, His sister and a nurse is suctioning the tracheostomy tube of James. Which of the following, if made by Wilma indicates that she is committing an error? A. Hyperventilating James with 100% oxygen before and after suctioning B. Instilling 3 to 5 ml normal saline to loosen up secretion C. Applying suction during catheter withdrawal D. Suction the client every hour 33. What size of suction catheter would Wilma use for James, who is 6 feet 5 inches in height and weighing approximately 145 lbs? A. Fr. 5 B. Fr. 10 C. Fr. 12 D. Fr. 18 34. Wilma is using a portable suction unit at home, What is the amount of suction required by James using this unit? A. 2-5 mmHg B. 5-10 mmHg C. 10-15 mmHg D. 20-25 mmHg 35. If a Wall unit is used, What should be the suctioning pressure required by James? A. 50-95 mmHg B. 95-110 mmHg C. 100-120 mmHg

D. 155-175 mmHg 36. Wilma was shocked to see that the Tracheostomy was dislodged. Both the inner and outer cannulas was removed and left hanging on James neck. What are the 2 equipments at james bedside that could help Wilma deal with this situation? A. New set of tracheostomy tubes and Oxygen tank B. Theophylline and Epinephrine C. Obturator and Kelly clamp D. Sterile saline dressing 37. Which of the following method if used by Wilma will best assure that the tracheostomy ties are not too tightly placed? A. Wilma places 2 fingers between the tie and neck B. The tracheotomy can be pulled slightly away from the neck C. James neck veins are not engorged D. Wilma measures the tie from the nose to the tip of the earlobe and to the xiphoid process. 38. Wilma knew that James have an adequate respiratory condition if she notices that A. James respiratory rate is 18 B. James Oxygen saturation is 91% C. There are frank blood suction from the tube D. There are moderate amount of tracheobronchial secretions 39. Wilma knew that the maximum time when suctioning James is A. 10 seconds B. 20 seconds C. 30 seconds D. 45 seconds SITUATION : Juan Miguel Lopez Zobel Ayala de Batumbakal was diagnosed with Acute Close Angle Glaucoma. He is being seen by Nurse Jet. 40. What specific manifestation would nurse Jet see in Acute close angle glaucoma that she would not see in an open angle glaucoma? A. Loss of peripheral vision B. Irreversible vision loss C. There is an increase in IOP

D. Pain 41. Nurse jet knew that Acute close angle glaucoma is caused by A. Sudden blockage of the anterior angle by the base of the iris B. Obstruction in trabecular meshwork C. Gradual increase of IOP D. An abrupt rise in IOP from 8 to 15 mmHg 42. Nurse jet performed a TONOMETRY test to Mr. Batumbakal. What does this test measures A. It measures the peripheral vision remaining on the client B. Measures the Intra Ocular Pressure C. Measures the Clients Visual Acuity D. Determines the Tone of the eye in response to the sudden increase in IOP. 43. The Nurse notices that Mr. Batumbakal cannot anymore determine RED from BLUE. The nurse knew that which part of the eye is affected by this change? A. IRIS B. PUPIL c. RODS [RETINA] D. CONES [RETINA] 44. Nurse Jet knows that Aqueous Humor is produce where? A. In the sub arachnoid space of the meninges B. In the Lateral ventricles C. In the Choroids D. In the Ciliary Body 45. Nurse Jet knows that the normal IOP is A. 8-21 mmHg B. 2-7 mmHg c. 31-35 mmHg D. 15-30 mmHg 46. Nurse Jet wants to measure Mr. Batumbakals CN II Function. What test would Nurse Jet implement to measure CN IIs Acuity? A. Slit lamp

B. Snellens Chart C. Woods light D. Gonioscopy 47. The Doctor orders pilocarpine. Nurse jet knows that the action of this drug is to A. Contract the Ciliary muscle B. Relax the Ciliary muscle C. Dilate the pupils D. Decrease production of Aqueous Humor 48. The doctor orders timolol [timoptic]. Nurse jet knows that the action of this drug is A. Reduce production of CSF B. Reduce production of Aquesous Humor C. Constrict the pupil D. Relaxes the Ciliary muscle 49. When caring for Mr. Batumbakal, Jet teaches the client to avoid A. Watching large screen TVs B. Bending at the waist C. Reading books D. Going out in the sun 50. Mr. Batumbakal has undergone eye angiography using an Intravenous dye and fluoroscopy. What activity is contraindicated immediately after procedure? A. Reading newsprint B. Lying down C. Watching TV D. Listening to the music 51. If Mr. Batumbakal is receiving pilocarpine, what drug should always be available in any case systemic toxicity occurs? A. Atropine Sulfate B. Pindolol [Visken] C. Naloxone Hydrochloride [Narcan] D. Mesoridazine Besylate [Serentil] SITUATION : Wide knowledge about the human ear, its parts and its functions will help a nurse

assess and analyze changes in the adult clients health. 52. Nurse Anna is doing a caloric testing to his patient, Aida, a 55 year old university professor who recently went into coma after being mauled by her disgruntled 3rd year nursing students whom she gave a failing mark. After instilling a warm water in the ear, Anna noticed a rotary nystagmus towards the irrigated ear. What does this means? A. Indicates a CN VIII Dysfunction B. Abnormal C. Normal D. Inconclusive

53. Ear drops are prescribed to an infant, The most appropriate method to administer the ear drops is A. Pull the pinna up and back and direct the solution towards the eardrum B. Pull the pinna down and back and direct the solution onto the wall of the canal C. Pull the pinna down and back and direct the solution towards the eardrum D. Pull the pinna up and back and direct the solution onto the wall of the canal 54. Nurse Jenny is developing a plan of care for a patient with Menieres disease. What is the priority nursing intervention in the plan of care for this particular patient? A. Air, Breathing, Circulation B. Love and Belongingness C. Food, Diet and Nutrition D. Safety 55. After mastoidectomy, Nurse John should be aware that the cranial nerve that is usually damage after this procedure is A. CN I B. CN II C. CN VII D. CN VI 56. The physician orders the following for the client with Menieres disease. Which of the following should the nurse question? A. Dipenhydramine [Benadryl] B. Atropine sulfate

C. Out of bed activities and ambulation D. Diazepam [Valium] 57. Nurse Anna is giving dietary instruction to a client with Menieres disease. Which statement if made by the client indicates that the teaching has been successful? A. I will try to eat foods that are low in sodium and limit my fluid intake B. I must drink atleast 3,000 ml of fluids per day C. I will try to follow a 50% carbohydrate, 30% fat and 20% protein diet D. I will not eat turnips, red meat and raddish 58. Peachy was rushed by his father, Steven into the hospital admission. Peachy is complaining of something buzzing into her ears. Nurse Joemar assessed peachy and found out It was an insect. What should be the first thing that Nurse Joemar should try to remove the insect out from peachys ear? A. Use a flashlight to coax the insect out of peachys ear B. Instill an antibiotic ear drops C. Irrigate the ear D. Pick out the insect using a sterile clean forceps 59. Following an ear surgery, which statement if heard by Nurse Oca from the patient indicates a correct understanding of the post operative instructions? A. Activities are resumed within 5 days B. I will make sure that I will clean my hair and face to prevent infection C. I will use straw for drinking D. I should avoid air travel for a while 60. Nurse Oca will do a caloric testing to a client who sustained a blunt injury in the head. He instilled a cold water in the clients right ear and he noticed that nystagmus occurred towards the left ear. What does this finding indicates? A. Indicating a Cranial Nerve VIII Dysfunction B. The test should be repeated again because the result is vague C. This is Grossly abnormal and should be reported to the neurosurgeon D. This indicates an intact and working vestibular branch of CN VIII 61. A client with Cataract is about to undergo surgery. Nurse Oca is preparing plan of care. Which of the following nursing diagnosis is most appropriate to address the long term need of this type of patient?

A. Anxiety R/T to the operation and its outcome B. Sensory perceptual alteration R/T Lens extraction and replacement C. Knowledge deficit R/T the pre operative and post operative self care D. Body Image disturbance R/T the eye packing after surgery

62. Nurse Joseph is performing a WEBERS TEST. He placed the tuning fork in the patients forehead after tapping it onto his knee. The client states that the fork is louder in the LEFT EAR. Which of the following is a correct conclusion for nurse Josph to make? A. He might have a sensory hearing loss in the left ear B. Conductive hearing loss is possible in the right ear C. He might have a sensory hearing loss in the right hear, and/or a conductive hearing loss in the left ear. D. He might have a conductive hearing loss in the right ear, and/or a sensory hearing loss in the left ear. 63. Aling myrna has Menieres disease. What typical dietary prescription would nurse Oca expect the doctor to prescribe? A. A low sodium , high fluid intake B. A high calorie, high protein dietary intake C. low fat, low sodium and high calorie intake D. low sodium and restricted fluid intake SITUATION : [ From DEC 1991 NLE ] A 45 year old male construction worker was admitted to a tertiary hospital for incessant vomiting. Assessment disclosed: weak rapid pulse, acute weight loss of .5kg, furrows in his tongue, slow flattening of the skin was noted when the nurse released her pinch. Temperature: 35.8 C , BUN Creatinine ratio : 10 : 1, He also complains for postural hypotension. There was no infection. 64. Which of the following is the appropriate nursing diagnosis? A. Fluid volume deficit R/T furrow tongue B. Fluid volume deficit R/T uncontrolled vomiting C. Dehydration R/T subnormal body temperature D. Dehydration R/T incessant vomiting 65. Approximately how much fluid is lost in acute weight loss of .5kg?

A. 50 ml B. 750 ml C. 500 ml D. 75 ml 66. Postural Hypotension is A. A drop in systolic pressure less than 10 mmHg when patient changes position from lying to sitting. B. A drop in systolic pressure greater than 10 mmHg when patient changes position from lying to sitting C. A drop in diastolic pressure less than 10 mmHg when patient changes position from lying to sitting D. A drop in diastolic pressure greater than 10 mmHg when patient changes position from lying to sitting 67. Which of the following measures will not help correct the patients condition A. Offer large amount of oral fluid intake to replace fluid lost B. Give enteral or parenteral fluid C. Frequent oral care D. Give small volumes of fluid at frequent interval 68. After nursing intervention, you will expect the patient to have 1. Maintain body temperature at 36.5 C 2. Exhibit return of BP and Pulse to normal 3. Manifest normal skin turgor of skin and tongue 4. Drinks fluids as prescribed A. 1,3 B. 2,4 C. 1,3,4 D. 2,3,4 SITUATION: A 65 year old woman was admitted for Parkinsons Disease. The charge nurse is going to make an initial assessment. 69. Which of the following is a characteristic of a patient with advanced Parkinsons disease? A. Disturbed vision B. Forgetfulness

C. Mask like facial expression D. Muscle atrophy 70. The onset of Parkinsons disease is between 50-60 years old. This disorder is caused by A. Injurious chemical substances B. Hereditary factors C. Death of brain cells due to old age D. Impairment of dopamine producing cells in the brain 71. The patient was prescribed with levodopa. What is the action of this drug? A. Increase dopamine availability B. Activates dopaminergic receptors in the basal ganglia C. Decrease acetylcholine availability D. Release dopamine and other catecholamine from neurological storage sites 72. You are discussing with the dietician what food to avoid with patients taking levodopa? A. Vitamin C rich food B. Vitamin E rich food C. Thiamine rich food D. Vitamin B6 rich food 73. One day, the patient complained of difficulty in walking. Your response would be A. You will need a cane for support B. Walk erect with eyes on horizon C. Ill get you a wheelchair D. Dont force yourself to walk SITUATION: Mr. Dela Isla, a client with early Dementia exhibits thought process disturbances. 74. The nurse will assess a loss of ability in which of the following areas? A. Balance B. Judgment C. Speech D. Endurance 75. Mr. Dela Isla said he cannot comprehend what the nurse was saying. He suffers from:

A. Insomnia B. Aphraxia C. Agnosia D. Aphasia 76. The nurse is aware that in communicating with an elderly client, the nurse will A. Lean and shout at the ear of the client B. Open mouth wide while talking to the client C. Use a low-pitched voice D. Use a medium-pitched voice 77. As the nurse talks to the daughter of Mr. Dela Isla, which of the following statement of the daughter will require the nurse to give further teaching? A. I know the hallucinations are parts of the disease B. I told her she is wrong and I explained to her what is right C. I help her do some tasks he cannot do for himself D. Ill turn off the TV when we go to another room 78. Which of the following is most important discharge teaching for Mr. Dela Isla A. Emergency Numbers B. Drug Compliance C. Relaxation technique D. Dietary prescription SITUATION : Knowledge of the drug PROPANTHELINE BROMIDE [Probanthine] Is necessary in treatment of various disorders. 79. What is the action of this drug? A. Increases glandular secretion for clients affected with cystic fibrosis B. Dissolve blockage of the urinary tract due to obstruction of cystine stones C. Reduces secretion of the glandular organ of the body D. Stimulate peristalsis for treatment of constipation and obstruction 80. What should the nurse caution the client when using this medication A. Avoid hazardous activities like driving, operating machineries etc. B. Take the drug on empty stomach C. Take with a full glass of water in treatment of Ulcerative colitis

D. I must take double dose if I missed the previous dose 81. Which of the following drugs are not compatible when taking Probanthine? A. Caffeine B. NSAID C. Acetaminophen D. Alcohol 82. What should the nurse tell clients when taking Probanthine? A. Avoid hot weathers to prevent heat strokes B. Never swim on a chlorinated pool C. Make sure you limit your fluid intake to 1L a day D. Avoid cold weathers to prevent hypothermia 83. Which of the following disease would Probanthine exert the much needed action for control or treatment of the disorder? A. Urinary retention B. Peptic Ulcer Disease C. Ulcerative Colitis D. Glaucoma SITUATION : Mr. Franco, 70 years old, suddenly could not lift his spoons nor speak at breakfast. He was rushed to the hospital unconscious. His diagnosis was CVA. 84. Which of the following is the most important assessment during the acute stage of an unconscious patient like Mr. Franco? A. Level of awareness and response to pain B. Papillary reflexes and response to sensory stimuli C. Coherence and sense of hearing D. Patency of airway and adequacy of respiration 85. Considering Mr. Francos conditions, which of the following is most important to include in preparing Francos bedside equipment? A. Hand bell and extra bed linen B. Sandbag and trochanter rolls C. Footboard and splint D. Suction machine and gloves

86. What is the rationale for giving Mr. Franco frequent mouth care? A. He will be thirsty considering that he is doesnt drink enough fluids B. To remove dried blood when tongue is bitten during a seizure C. The tactile stimulation during mouth care will hasten return to consciousness D. Mouth breathing is used by comatose patient and itll cause oral mucosa dying and cracking. 87. One of the complications of prolonged bed rest is decubitus ulcer. Which of the following can best prevent its occurrence? A. Massage reddened areas with lotion or oils B. Turn frequently every 2 hours C. Use special water mattress D. Keep skin clean and dry 88. If Mr. Francos Right side is weak, What should be the most accurate analysis by the nurse? A. Expressive aphasia is prominent on clients with right sided weakness B. The affected lobe in the patient is the Right lobe C. The client will have problems in judging distance and proprioception D. Clients orientation to time and space will be much affected SITUATION : a 20 year old college student was rushed to the ER of PGH after he fainted during their ROTC drill. Complained of severe right iliac pain. Upon palpation of his abdomen, Ernie jerks even on slight pressure. Blood test was ordered. Diagnosis is acute appendicitis. 89. Which result of the lab test will be significant to the diagnosis? A. RBC : 4.5 TO 5 Million / cu. mm. B. Hgb : 13 to 14 gm/dl. C. Platelets : 250,000 to 500,000 cu.mm. D. WBC : 12,000 to 13,000/cu.mm 90. Stat appendectomy was indicated. Pre op care would include all of the following except? A. Consent signed by the father B. Enema STAT C. Skin prep of the area including the pubis D. Remove the jewelries 91. Pre-anesthetic med of Demerol and atrophine sulfate were ordered to :

A. Allay anxiety and apprehension B. Reduce pain C. Prevent vomiting D. Relax abdominal muscle 92. Common anesthesia for appendectomy is A. Spinal B. General C. Caudal D. Hypnosis 93. Post op care for appendectomy include the following except A. Early ambulation B. Diet as tolerated after fully conscious C. Nasogastric tube connect to suction D. Deep breathing and leg exercise 94. Peritonitis may occur in ruptured appendix and may cause serious problems which are 1. Hypovolemia, electrolyte imbalance 2. Elevated temperature, weakness and diaphoresis 3. Nausea and vomiting, rigidity of the abdominal wall 4. Pallor and eventually shock A. 1 and 2 B. 2 and 3 C. 1,2,3 D. All of the above 95. If after surgery the patients abdomen becomes distended and no bowel sounds appreciated, what would be the most suspected complication? A. Intussusception B. Paralytic Ileus C. Hemorrhage D. Ruptured colon 96. NGT was connected to suction. In caring for the patient with NGT, the nurse must

A. Irrigate the tube with saline as ordered B. Use sterile technique in irrigating the tube C. advance the tube every hour to avoid kinks D. Offer some ice chips to wet lips 97. When do you think the NGT tube be removed? A. When patient requests for it B. Abdomen is soft and patient asks for water C. Abdomen is soft and flatus has been expelled D. B and C only Situation: Amanda is suffering from chronic arteriosclerosis Brain syndrome she fell while getting out of the bed one morning and was brought to the hospital, and she was diagnosed to have cerebrovascular thrombosis thus transferred to a nursing home. 98. What do you call a STROKE that manifests a bizarre behavior? A. Inorganic Stroke B. Inorganic Psychoses C. Organic Stroke D. Organic Psychoses 99. The main difference between chronic and organic brain syndrome is that the former A. Occurs suddenly and reversible B. Is progressive and reversible C. tends to be progressive and irreversible D. Occurs suddenly and irreversible 100. Which behavior results from organic psychoses? A. Memory deficit B. Disorientation C. Impaired Judgement D. Inappropriate affect

OBSTETRICS-MATERNAL AND CHILD HEALTH NURSING

SITUATION : Aling Martha, a 32 year old fish vendor from baranggay matahimik came to see you at the prenatal clinic. She brought with her all her three children. Maye, 1 year 6 months; Joy, 3 and Dan, 7 years old. She mentioned that she stopped taking oral contraceptives several months ago and now suspects she is pregnant. She cannot remember her LMP. 1. Which of the following would be useful in calculating Aling Martha's EDC? A. Appearance of linea negra B. First FHT by fetoscope C. Increase pulse rate D. Presence of edema 2. Which hormone is necessary for a positive pregnancy test? A. Progesterone B. HCG C. Estrogen D. Placental Lactogen 3. With this pregnancy, Aling Martha is a A. P3 G3 B. Primigravida C. P3 G4 D. P0 G3

4. In explaining the development of her baby, you identified in chronological order of growth of the fetus as it occurs in pregnancy as A. Ovum, embryo, zygote, fetus, infant B. Zygote, ovum, embryo, fetus, infant C. Ovum, zygote, embryo, fetus, infant D. Zygote, ovum, fetus, embryo, infant 5. Aling Martha states she is happy to be pregnant. Which behavior is elicited by her during your assessment that would lead you to think she is stressed? A. She told you about her drunk husband B. She states she has very meager income from selling C. She laughs at every advise you give even when its not funny D. She has difficulty following instructions 6. When teaching Aling Martha about her pregnancy, you should include personal common discomforts. Which of the following is an indication for prompt professional supervision? A. Constipation and hemorrhoids B. Backache C. Facial edema D. frequent urination 7. Which of the following statements would be appropriate for you to include in Aling Martha's prenatal teaching plan? A. Exercise is very tiresome, it should be avoided B. Limit your food intake C. Smoking has no harmful effect on the growth and development of fetus D. Avoid unnecessary fatigue, rest periods should be included in you schedule 8. The best advise you can give to Aling Martha regarding prevention of varicosities is A. Raise the legs while in upright position and put it against the wall several times a day B. Lay flat for most hours of the day C. Use garters with nylon stocking D. Wear support hose 9. In a 32 day menstrual cycle, ovulation usually occurs on the

A. 14th day after menstruation B. 18th day after menstruation C. 20th day after menstruation D. 24th day after menstruation 10. Placenta is the organ that provides exchange of nutrients and waste products between mother and fetus. This develops by A. First month B. Third month C. Fifth month D. Seventh month 11. In evaluating the weight gain of Aling Martha, you know the minimum weight gain during pregnancy is A. 2 lbs/wk B. 5 lbs/wk C. 7 lbs/wk D. 10 lbs/wk 12. The more accurate method of measuring fundal height is A. Millimeter B. Centimeter C. Inches D. Fingerbreadths 13. To determine fetal position using Leopold's maneuvers, the first maneuver is to A. Determine degree of cephalic flexion and engagement B. Determine part of fetus presenting into pelvis C. Locate the back,arms and legs D. Determine what part of fetus is in the fundus 14. Aling Martha has encouraged her husband to attend prenatal classes with her. During the prenatal class, the couple expressed fear of pain during labor and delivery. The use of touch and soothing voice often promotes comfort to the laboring patient. This physical intervention is effective because A. Pain perception is interrupted B. Gate control fibers are open

C. It distracts the client away from the pain D. Empathy is communicated by a caring person 15. Which of the following could be considered as a positive sign of pregnancy ? A. Amenorrhea, nausea, vomiting B. Frequency of urination C. Braxton hicks contraction D. Fetal outline by sonography SITUATION : Maternal and child health is the program of the department of health created to lessen the death of infants and mother in the Philippines. 16. What is the goal of this program? A. Promote mother and infant health especially during the gravida stage B. Training of local hilots C. Direct supervision of midwives during home delivery D. Health teaching to mother regarding proper newborn care 17. One philosophy of the maternal and child health nursing is A. All pregnancy experiences are the same for all woman B. Culture and religious practices have little effect on pregnancy of a woman C. Pregnancy is a part of the life cycle but provides no meaning D. The father is as important as the mother 18. In maternal care, the PHN responsibility is A. To secure all information that would be needing in birth certificate B. To protect the baby against tetanus neonatorum by immunizing the mother with DPT C. To reach all pregnant woman D. To assess nutritional status of existing children 19. This is use when rendering prenatal care in the rural health unit. It serves as a guide in Identification of risk factors A. Underfive clinic chart B. Home based mother's record C. Client list of mother under prenatal care D. Target list of woman under TT vaccination

20. The schedule of prenatal visit in the RHU unit is A. Once from 1st up to 8th month, weekly on the 9th month B. Twice in 1st and second trimester, weekly on third trimester C. Once in each trimester, more frequent for those at risk D. Frequent as possible to determine the presence of FHT each week SITUATION : Knowledge of the menstrual cycle is important in maternal health nursing. The following questions pertains to the process of menstruation 21. Menarche occurs during the pubertal period, Which of the following occurs first in the development of female sex characteristics? A. Menarche B. Accelerated Linear Growth C. Breast development D. Growth of pubic hair 22. Which gland is responsible for initiating the menstrual cycle? A. Ovaries B. APG C. PPG D. Hypothalamus 23. The hormone that stimulates the ovaries to produce estrogen is A. GnRH B. LH C. LHRF D. FSH 24. Which hormone stimulates oocyte maturation? A. GnRH B. LH C. LHRF D. FSH 25. When is the serum estrogen level highest in the menstrual cycle? A. 3rd day

B. 13th day C. 14th day D. End of menstrual cycle 26. To correctly determine the day of ovulation, the nurse must A. Deduct 14 days at the mid of the cycle B. Subtract two weeks at cycle's end C. Add 7 days from mid of the cycle D. Add 14 days from the end of the cycle 27. The serum progesterone is lowest during what day of the menstrual cycle? A. 3rd day B. 13th day C. 14th day D. End of menstrual cycle 28. How much blood is loss on the average during menstrual period? A. Half cup B. 4 tablespoon C. 3 ounces D. 1/3 cup 29. Menstruation occurs because of which following mechanism? A. Increase level of estrogen and progesterone level B. Degeneration of the corpus luteum C. Increase vascularity of the endothelium D. Surge of hormone progesterone 30. If the menstrual cycle of a woman is 35 day cycle, she will approximately A. Ovulate on the 21st day with fertile days beginning on the 16th day to the 26th day of her cycle B. Ovulate on the 21st day with fertile days beginning on the 16th day to the 21th day of her cycle C. Ovulate on the 22st day with fertile days beginning on the 16th day to the 26th day of her cycle D. Ovulate on the 22st day with fertile days beginning on the 14th day to the 30th day of her cycle

SITUATION : Wide knowledge about different diagnostic tests during pregnancy is an essential arsenal for a nurse to be successful. 31. The Biparietal diameter of a fetus is considered matured if it is atleast A. 9.8 cm B. 8.5 cm C. 7.5 cm D. 6 cm 32. Quickening is experienced first by multigravida clients. At what week of gestation do they start to experience quickening? A. 16th B. 20th C. 24th D. 28th 33. Before the start of a non stress test, The FHR is 120 BPM. The mother ate the snack and the practitioner noticed an increase from 120 BPM to 135 BPM for 15 seconds. How would you read the result? A. Abnormal B. Non reactive C. Reactive D. Inconclusive, needs repeat 34. When should the nurse expect to hear the FHR using a fetoscope? A. 2nd week B. 8th week C. 2nd month D. 4th month 35. When should the nurse expect to hear FHR using doppler Ultrasound? A. 8th week B. 8th month C. 2nd week D. 4th month

36. The mother asks, What does it means if her maternal serum alph feto protein is 35 ng/ml? The nurse should answer A. It is normal B. It is not normal C. 35 ng/ml indicates chromosomal abberation D. 35 ng/ml indicates neural tube defect 37. Which of the following mothers needs RHOGAM? A. RH + mother who delivered an RH - fetus B. RH - mother who delivered an RH + fetus C. RH + mother who delivered an RH + fetus D. RH - mother who delivered an RH - fetus 38. Which family planning method is recommended by the department of health more than any other means of contraception? A. Fertility Awareness Method B. Condom C. Tubal Ligation D. Abstinence 39. How much booster dose does tetanus toxoid vaccination for pregnant women has? A. 2 B. 5 C. 3 D. 4 40. Baranggay pinoybsn.tk has 70,000 population. How much nurse is needed to service this population? A. 5 B. 7 C. 50 D. 70 SITUATION : Reproductive health is the exercise of reproductive right with responsibility. A married couple has the responsibility to reproduce and procreate. 41. Which of the following is ONE of the goals of the reproductive health concept?

A. To achieve healthy sexual development and maturation B. To prevent specific RH problem through counseling C. Provide care, treatment and rehabilitation D. To practice RH as a way of life of every man and woman 42. Which of the following is NOT an element of the reproductive health? A. Maternal and child health and nutrition B. Family planning C. Prevention and management of abortion complication D. Healthy sexual development and nutrition 43. In the international framework of RH, which one of the following is the ultimate goal? A. Women's health in reproduction B. Attainment of optimum health C. Achievement of women's status D. Quality of life 44. Which one of the following is a determinant of RH affecting woman's ability to participate in social affairs? A. Gender issues B. Socio-Economic condition C. Cultural and psychosocial factors D. Status of women 45. In the philippine RH Framework. which major factor affects RH status? A. Women's lower level of literacy B. Health service delivery mechanism C. Poor living conditions lead to illness D. Commercial sex workers are exposed to AIDS/STD. 46. Which determinant of reproductive health advocates nutrition for better health promotion and maintain a healthful life? A. Socio-Economic conditions B. Status of women C. Social and gender issues D. Biological, Cultural and Psychosocial factors

47. Which of the following is NOT a strategy of RH? A. Increase and improve contraceptive methods B. Achieve reproductive intentions C. Care provision focused on people with RH problems D. Prevent specific RH problem through information dessemination 48. Which of the following is NOT a goal of RH? A. Achieve healthy sexual development and maturation B. Avoid illness/diseases, injuries, disabilities related to sexuality and reproduction C. Receive appropriate counseling and care of RH problems D. Strengthen outreach activities and the referral system 49. What is the VISION of the RH? A. Attain QUALITY OF LIFE B. Practice RH as a WAY OF LIFE C. Prevent specific RH problem D. Health in the hands of the filipino SITUATION : Baby G, a 6 hours old newborn is admitted to the NICU because of low APGAR Score. His mother had a prolonged second stage of labor 50. Which of the following is the most important concept associated with all high risk newborn? A. Support the high-risk newborn's cardiopulmonary adaptation by maintaining adequate airway B. Identify complications with early intervention in the high risk newborn to reduce morbidity and mortality C. Assess the high risk newborn for any physical complications that will assist the parent with bonding D. Support mother and significant others in their request toward adaptation to the high risk newborn 51. Which of the following would the nurse expect to find in a newborn with birth asphyxia? A. Hyperoxemia B. Acidosis C. Hypocapnia D. Ketosis

52. When planning and implementing care for the newborn that has been successfully resuscitated, which of the following would be important to assess? A. Muscle flaccidity B. Hypoglycemia C. Decreased intracranial pressure D. Spontaneous respiration SITUATION : Nurses should be aware of the different reproductive problems. 53. When is the best time to achieve pregnancy? A. Midway between periods B. Immediately after menses end C. 14 days before the next period is expected D. 14 days after the beginning of the next period 54. A factor in infertility maybe related to the PH of the vaginal canal. A medication that is ordered to alter the vaginal PH is: A. Estrogen therapy B. Sulfur insufflations C. Lactic acid douches D. Na HCO3 Douches 55. A diagnostic test used to evaluate fertility is the postcoital test. It is best timed A. 1 week after ovulation B. Immediately after menses C. Just before the next menstrual period D. Within 1 to 2 days of presumed ovulation 56. A tubal insufflation test is done to determine whether there is a tubal obstruction. Infertility caused by a defect in the tube is most often related to a A. Past infection B. Fibroid Tumor C. Congenital Anomaly D. Previous injury to a tube 57. Which test is commonly used to determine the number, motility and activity of sperm is

the A. Rubin test B. Huhner test C. Friedman test D. Papanicolau test 58. In the female, Evaluation of the pelvic organs of reproduction is accomplished by A. Biopsy B. Cystoscopy C. Culdoscopy D. Hysterosalpingogram 59. When is the fetal weight gain greatest? A. 1st trimester B. 2nd trimester C. 3rd trimester D. from 4th week up to 16th week of pregnancy 60. In fetal blood vessel, where is the oxygen content highest? A. Umbilical artery B. Ductus Venosus C. Ductus areteriosus D. Pulmonary artery 61. The nurse is caring for a woman in labor. The woman is irritable, complains of nausea and vomits and has heavier show. The membranes rupture. The nurse understands that this indicates A. The woman is in transition stage of labor B. The woman is having a complication and the doctor should be notified C. Labor is slowing down and the woman may need oxytocin D. The woman is emotionally distraught and needs assistance in dealing with labor SITUATION : Cynthia, a 32 year old primigravida at 39-40 weeks AOG was admitted to the labor room due to hypogastric and lumbo-sacral pains. IE revealed a fully dilated, fully effaced cervix. Station 0. 62. She is immediately transferred to the DR table. Which of the following conditions signify

that delivery is near? I - A desire to defecate II - Begins to bear down with uterine contraction III - Perineum bulges IV - Uterine contraction occur 2-3 minutes intervals at 50 seconds duration A. I,II,III B. I,II,III,IV C. I,III,IV D. II,III,IV 63. Artificial rupture of the membrane is done. Which of the following nursing diagnoses is the priority? A. High risk for infection related to membrane rupture B. Potential for injury related to prolapse cord C. Alteration in comfort related to increasing strength of uterine contraction D. Anxiety related to unfamiliar procedure 64. Cynthia complains of severe abdominal pain and back pain during contraction. Which two of the following measures will be MOST effective in reducing pain? I - Rubbing the back with a tennis ball II- Effleurage III-Imagery IV-Breathing techniques A. II,IV B. II,III C. I,IV D. I,II 65. Lumbar epidural anesthesia is administered. Which of the following nursing responsibilities should be done immediately following procedure? A. Reposition from side to side B. Administer oxygen C. Increase IV fluid as indicated D. Assess for maternal hypotension 66. Which is NOT the drug of choice for epidural anesthesia?

A. Sensorcaine B. Xylocaine C. Ephedrine D. Marcaine SITUATION : Helen, a 24 year old G4P3 at full term gestation is brought to the ER after a gush of fluid passes through here vagina while doing her holiday shopping. 67. She is brought to the triage unit. The FHT is noted to be 114 bpm. Which of the following actions should the nurse do first? A. Monitor FHT ever 15 minutes B. Administer oxygen inhalation C. Ask the charge nurse to notify the Obstetrician D. Place her on the left lateral position 68. The nurse checks the perineum of Helen. Which of the following characteristic of the amniotic fluid would cause an alarm to the nurse? A. Greenish B. Scantly C. Colorless D. Blood tinged 69. Helen asks the nurse. "Why do I have to be on complete bed rest? I am not comfortable in this position." Which of the following response of the nurse is most appropriate? A. Keeping you on bed rest will prevent possible cord prolapse B. Completed bed rest will prevent more amniotic fluid to escape C. You need to save your energy so you will be strong enough to push later D. Let us ask your obstetrician when she returns to check on you 70. Helen wants to know how many fetal movements per hour is normal, the correct response is A. Twice B. Thrice C. Four times D. 10-12 times 71. Upon examination by the obstetrician, he charted that Helen is in the early stage of labor.

Which of the following is true in this state? A. Self-focused B. Effacement is 100% C. Last for 2 hours D. Cervical dilation 1-3 cm SITUATION : Maternal and child health nursing a core concept of providing health in the community. Mastery of MCH Nursing is a quality all nurse should possess. 72. When should be the 2nd visit of a pregnant mother to the RHU? A. Before getting pregnant B. As early in pregnancy C. Second trimester D. Third trimester 73. Which of the following is NOT a standard prenatal physical examination? A. Neck examination for goiter B. Examination of the palms of the hands for pallor C. Edema examination of the face hands, and lower extremeties D. Examination of the legs for varicosities 74. Which of the following is NOT a basic prenatal service delivery done in the BHS? A. Oral/Dental check up B. Laboratory examination C. Treatment of diseases D. Iron supplementation 75. How many days and how much dosage will the IRON supplementation be taken? A. 365 days / 300 mg B. 210 days / 200 mg C. 100 days/ 100mg D. 50 days / 50 mg 76. When should the iron supplementation starts and when should it ends? A. 5th month of pregnancy to 2nd month post partum B. 1st month of pregnancy to 5th month post partum

C. As early in pregnancy up to 9th month of pregnancy D. From 1st trimester up to 6 weeks post partum 77. In malaria infested area, how is chloroquine given to pregnant women? A. 300 mg / twice a month for 9 months B. 200 mg / once a week for 5 months C. 150 mg / twice a week for the duration of pregnancy D. 100 mg / twice a week for the last trimester of pregnancy 78. Which of the following mothers are qualified for home delivery? A. Pre term B. 6th pregnancy C. Has a history of hemorrhage last pregnancy D. 2nd pregnancy, Has a history of 20 hours of labor last pregnancy. 79. Which of the following is not included on the 3 Cs of delivery? A. Clean Surface B. Clean Hands C. Clean Equipments D. Clean Cord 80. Which of the following is unnecessary equipment to be included in the home delivery kit? A. Boiled razor blade B. 70% Isopropyl Alcohol C. Flashlight D. Rectal and oral thermometer SITUATION : Pillar is admitted to the hospital with the following signs : Contractions coming every 10 minutes, lasting 30 seconds and causing little discomfort. Intact membranes without any bloody shows. Stable vital signs. FHR = 130bpm. Examination reveals cervix is 3 cm dilated with vertex presenting at minus 1 station. 81. On the basis of the data provided above, You can conclude the pillar is in the A. In false labor B. In the active phase of labor C. In the latent phase of labor D. In the transitional phase of labor

82. Pitocin drip is started on Pilar. Possible side effects of pitocin administration include all of the following except A. Diuresis B. Hypertension C. Water intoxication D. Cerebral hemorrhage 83. The normal range of FHR is approximately A. 90 to 140 bpm B. 120 to 160 bpm C. 100 to 140 bpm D. 140 to 180 bpm 84. A negative 1 [-1] station means that A. Fetus is crowning B. Fetus is floating C. Fetus is engaged D. Fetus is at the ischial spine 85. Which of the following is characteristics of false labor A. Bloody show B. Contraction that are regular and increase in frequency and duration C. Contraction are felt in the back and radiates towards the abdomen D. None of the above 86. Who's Theory of labor pain that states that PAIN in labor is cause by FEAR A. Bradley B. Simpson C. Lamaze D. Dick-Read 87. Which sign would alert the nurse that Pillar is entering the second stage of labor? A. Increase frequency and intensity of contraction B. Perineum bulges and anal orifice dilates C. Effacement of internal OS is 100%

D. Vulva encircles the largest diameter of presenting part 88. Nursing care during the second stage of labor should include A. Careful evaluation of prenatal history B. Coach breathing, Bear down with each contraction and encourage patient. C. Shave the perineum D. Administer enema to the patient SITUATION : Baby boy Jose was delivered spontaneously following a term pregnancy. Apgar scores are 8 and 9 respectively. Routine procedures are carried out. 89. When is the APGAR Score taken? A. Immediately after birth and at 30 minutes after birth B. At 5 minutes after birth and at 30 minutes after birth C. At 1 minute after birth and at 5 minutes after birth D. Immediately after birth and at 5 minutes after birth 90. The best way to position a newboarn during the first week of life is to lay him A. Prone with head slightly elevated B. On his back, flat C. On his side with his head flat on bed D. On his back with head slightly elevated 91. Baby boy Jose has a large sebaceous glands on his nose, chin, and forehead. These are known as A. Milia B. Lanugo C. Hemangiomas D. Mongolian spots 92. Baby boy Jose must be carefully observed for the first 24 hours for A. Respiratory distress B. Duration of cry C. Frequency of voiding D. Range in body temperature 93. According to the WHO , when should the mother starts breastfeeding the infant?

A. Within 30 minutes after birth B. Within 12 hours after birth C. Within a day after birth D. After infant's condition stabilizes 94. What is the BEST and most accurate method of measuring the medication dosage for infants and children? A. Weight B. Height C. Nomogram D. Weight and Height 95. The first postpartum visit should be done by the mother within A. 24 hours B. 3 days C. a week D. a month 96. The major cause of maternal mortality in the Philippines is A. Infection B. Hemorrhage C. Hypertension D. Other complications related to labor,delivery and puerperium 97. According to the WHO, what should be the composition of a commercialized Oral rehydration salt solution? A. Potassium : 1.5 g. ; Sodium Bicarbonate 2.5g ; Sodium Chloride 3.5g; Glucose 20 g. A. Potassium : 1.5 g. ; Sodium Bicarbonate 2.5g ; Sodium Chloride 3.5g; Glucose 10 g. A. Potassium : 2.5 g. ; Sodium Bicarbonate 3.5g ; Sodium Chloride 4.5g; Glucose 20 g. A. Potassium : 2.5 g. ; Sodium Bicarbonate 3.5g ; Sodium Chloride 4.5g; Glucose 10 g. 98. In preparing ORESOL at home, The correct composition recommnded by the DOH is A. 1 glass of water, 1 pinch of salt and 2 tsp of sugar B. 1 glass of water, 2 pinch of salt and 2 tsp of sugar C. 1 glass of water, 3 pinch of salt and 4 tsp of sugar D. 1 glass of water, 1 pinch of salt and 1 tsp of sugar

99. Milk code is a law that prohibits milk commercialization or artificial feeding for up to 2 years. Which law provides its legal basis? A. Senate bill 1044 B. RA 7600 C. Presidential Proclamation 147 D. EO 51 100. A 40 year old mother in her third trimester should avoid? A. Traveling B. Climbing C. Smoking D. Exercising