Title RECALLS 13 (NP2) - STUDENT COPY ✅

RECALLS EXAMINATION 13 NURSING PRACTICE II CARE OF HEALTHY / AT RISK MOTHER AND CHILD NOVEMBER 2024 Philippine Nurse Licensure Examination Review GENERAL INSTRUCTIONS: 1. This test questionnaire contains 100 test questions 2. Shade only one (1) box for each question on your answer sheets. Two or more boxes shaded will invalid your answer. 3. AVOID ERASURES. 4. Detach one (1) answer sheet from the bottom of your Examinee ID/Answer Sheet Set. 5. Write the subject title “NURSING PRACTICE II” on the box provided Situation 1- Patient Heather a gravida 1, para 0. Patient is admitted at the labor room. Her cervix is 100% effaced, and upon IE, her cervix is 3 cm dilated, the fetus is at + 1 station. Staff Nurse Regina attends to her. 1. Taken from the assessment data above that the fetus is at + station, how will Nurse Regina interpret this? That the head of the fetus is _________. A. Below the ischial spines B. Visible at the vaginal opening C. Not yet engaged D. Entering the pelvic inlet 2. Nurse Regina monitors the contractions of the patient. She recorded the contractions as follows: started at 10:00 A.M; another began at 10:15 A.M. In MINUTES, what is the frequency of the contractions? A. 10 B. 9 C. 15 D. 14 3. Nurse Regina assesses the duration of the patient’s contractions by timing them from ________ to ________. A. Beginning of one contraction to the beginning of the next contraction B. End of the contraction to the beginning of the next contraction C. End of the contraction to the end of the next contraction D. Beginning of one contraction to the end of the same contraction 4. After doing Leopold’s maneuvers on the patient I labor, the nurse determines that the fetus is in the ROA position. Where should the nurse place the Doppler to BEST auscultate the fetal heart tones? A. Below the umbilicus near the left groin B. Below the umbilicus on the right side C. Above the umbilicus in the midline D. Above the umbilicus on the left on the left side 5. Patient Heather was given epidural anesthesia. This indicates late deceleration of the fetus and so the nurse has to do important nursing interventions. ARRANGE the following nursing interventions in ORDER or PRIORITY. 1) Increase intravenous fluids 2) Change position of the patient to the left side lying 3) Reassess fetal heart rate pattern 4) Document intervention and maternal/fetal response A. 3 2 1 4 B. 3 4 1 2 C. 4 2 3 1 D. 2 3 4 1 Situation 2 – Patient Helen, who is in the third trimester, arrives at the hospital with vaginal bleeding. She states that she snorted cocaine approximately 2 hours ago. 6. Which defined complication is MOST likely causing the client’s vaginal bleeding? A. Premature separation of normally implanted placenta B. Pregnancy outside the uterus C. Termination of pregnancy before the age of viability D. Abnormal lower implantation of the placenta 7. The abdominal pain associated with abruption placentae may be INITIALLY caused by which of the following? A. Disseminated intravascular coagulation B. Blood in the myometrium C. Hemorrhagic shock D. Concealed haemorrhage 8. The bleeding following severe abruption placentae is usually caused by which of the following condition? A. Thrombocytopenia B. Hyperglobulinemia C. Polycythemia D. hypofibrinogenemia 9. What should the nurse prepare for the POSSIBLE order of the physician? A. The administration of the oxytocin B. A high- forceps birth C. An immediate caesarean birth D. The insertion of a fetal monitor 10. Abruption Placenta can cause hemorrhagic disorder which can lead to hypovolemic shock. What is the LATE sign of hypovolemic shock that the nurse should watch for? A. Hypertension B. Tachycardia C. Hypotension D. Tachypnea Situation 3- A nurse is performing an admission assessment on Tonton a 4-year-old, who has been diagnosed with nephrotic syndrome. 11. What sign will BEST support the medical diagnosis of nephrosis? A. Gross hematuria, tea-colored, scanty urine B. History of a streptococcal infection C. Periorbitaledema D. Anasarca 12. Tonton receives prednisone as the major treatment for his nephrosis. Which of the following actions should be observed by the nurse in the administration of prednisone? A. All of the options. B. Administer the drug on a full stomach. C. Monitor Carlo’s temperature. D. Protect Carlo from infection. 13. Which side effect of prednisone will be MOST prominent on Tonton and for which he should be prepared before its administration? A. Hypotension B. Decreased weight C. mooning of face D. vomiting 14. What is the nursing diagnosis for a child with severe edema caused from nephrotic syndrome? It is risk for_________. A. Impaired skin integrity B. Constipation 1 | Page
C. Ineffective thermoregulation D. Imbalanced nutrition more than body requirements 15. What will be the APPROPRIATE recommend diet for Tonton? A. High iron, no protein B. High calorie, high protein C. High sodium, high protein D. Low sodium, moderate protein Situation 4- Nurse Even works in the research unit of the Prinsesa Urduja Women’s Clinic. In the close monitoring of their patients using oral contraceptives (OC), she noted several cases of myocardial infarction (MI). 16. To establish the relationship between MI and OC, Nurse Even should make a research proposal for which of the following STUDY design? A. Retrospective B. incidence C. Prospective cohort D. cross- sectional 17. Since OCs are categorized into 1 st , 2 nd and 3 rd generations, Nurse Even decided to study not only the relationship of MI and OC but also which of the three generations of OCs will have the highest risk for MI. Hence, which of the following groups will she include in her study? A. Those who do not take OC, and those who take OC from 1 st , 2 nd , ad 3 rd OCs. B. All those who take OC and those who do not. C. Those who take 1 st OC 2 nd OC and 3 rd OC. D. Those with MI and those with no MI. 18. Statistical analyses revealed odds ratio for MI among women who used any type of OC, as compared with non-users, was .99. What does this mean? A. Accept the null hypothesis; there is no significant relationship between MI and OC. B. The study focused on the three groups: 1 st OC users with MI, 2 nd OC users with MI and 3 rd OC users with MI. C. There is a relationship between MI and OC and the risk of MI among users of any type of oral contraceptive is twice that of non users. D. The odds of getting MI among OC users and those who are not users is 1:2 19. Which of the following is the independent variable of the study? A. Highest risk B. Three generation of OC C. OC D. MI 20. Identify the groups in the study that will validate the occurrence of the MI among OC users. A. Old cases of MI B. Prevalence of MI C. old and new cases of MI D. incidence of MI Situation 5- Sugar, G2 P3, is a Type I diabetes mellitus (DM) since she was 10 years old. She is in her first trimester of pregnancy. Insu Ling is her nurse. 21. What could be the MOST possible effect of DM to Sugar? She can have ______. A. Ketoacidosis B. Hyperinsulinism C. Hyperglycemia D. Hypoglycemia 22. Which of the following would require an increased dose of medication once Sugar is in the second half of pregnancy? A. Insulin B. Pancreatic enzymes C. estrogenic hormone D. antihypertensives 23. What is the route of administration for insulin during pregnancy? A. Intravenous B. Subcutaneous C. oral D. shot with flex pen 24. Considering Sugar’s condition, Nurse Insu Ling will anticipate what effect to the fetus? The condition will be_______. A. Large for gestational age B. Macrosomia C. Intrauterine growth retardation (IUGR) D. Meningomyelocele 25. On the first postpartum day, which of the following requirements for insulin will be anticipated by the nurse to be ordered by the physician? A. Remain unchanged B. Decrease sharply and suddenly C. Increase rapidly D. Decrease slowly and steady Situation 6- Mrs. Pugita, gravida 3 para 3003, is admitted to the postpartal unit after an uncomplicated labor and vaginal delivery. She opted to breastfeed her baby. Nurse Jasmin is around to take care of her. 26. The first day after delivery, Mr. Pugita tells the nurse that his wife has been talking constantly about her recent delivery experience. He asks if this is a sign of postpartal blues. What should be the BEST response of the nurse? A. “Do you feel uncomfortable about her talking on her delivery experience?” B. “Yes, it’s clear sign of post-partum blues. She may need a psychiatric evalution.” C. “This is a normal reaction. It allows her to accept the reality of the birth of your baby.” D. “No, you should divert her attention away from her delivery.” 27. Later that day, Mrs. Pugita tells Nurse Jasmin that she has urinated four times within the last hour but only in small amounts. What should be the INITIAL ACTION of the nurse? A. Explain that this is normal during the first 24 hours after delivery. B. Palpate Mrs.Alim’s fundus to assess uterine consistency and location. C. Catheterize Mrs.Alim immediately to expel any retained urine. D. Begin measuring and recording and recording Mrs.Alim’s intake and output. 28. Which assessment finding is MOST indicative that Mrs. Pugita is developing puerperal infection? A. Increased pulse rate B. Foul- smelling lochia C. Elevated body temperature D. A white blood cell count of 25,000/mcg 29. Mrs. Pugita asks Nurse Jasmin when her menstrual period will return. The nurse answers that a breastfeeding patient typically resumes menstruating in about____________. A. 8 to 12 weeks B. 3 to 6 months C. 4 to 6 months D. 4 to 6 weeks 30. Mrs. Pugita complains of pain due to breast engorgement. What will the nurse do to encourage her to continue breastfeeding? A. Let her continue breastfeeding on schedule. B. Put hot compress over the breast for 15 minutes before breastfeeding. C. Put cold compress over the breast for 15 minutes before breastfeeding. D. Let her continue breastfeeding on demand. Situation 7- Nurse Jubel is collecting data from a newly admitted patient, Mrs. Jaclyn, who is pregnant with twins. She has a healthy 3-year-old child who was delivered at 38 weeks. She also revealed that she does not have a history of abortion nor fetal demise. Her last menstrual period began February 7, 2017 and ended February 12, 2017. 31. What is the GTPAL for Mrs. Jaclyn? A. G = 1, T = 1 , P = 1, A = 0, L = 1 B. G = 2, T = 0 , P = 0, A = 0, L = 1 C. G = 3, T = 2 , P = 0, A = 0, L = 1 D. G = 2, T = 1 , P = 0, A = 0, L = 1 32. What is the expected change in the hemotologic system that occurs during the END of the first trimester of pregnancy that Nurse Jubel should recognize? 2 | Page
A. An increase in hematocrit B. A decrease in WBC’s C. An increase in blood volume D. A decrease in sedimentation rate 33. Mrs. Jaclyn asks about the functions of placenta. Which of the following items should Nurse Jubel include in the teaching plan? 1) The placenta filters the fetal urine. 2) Fetal and maternal blood mix in the placenta to exchange nutrients. 3) The placenta filters the alcohol from the mother’s blood. 4) Substances are exchanged by the placenta without mixing the maternal and fetal blood. 5) Fetal respiration, nutrition and excretion are carried out by the placenta. A. 1, 2, 3 B. 4, 5 C. 3, 4, 5 D. 1, 2 34. Mrs. Jaclyn asks “When will be my expected date of delivery (EDD)?” Based on her knowledge of Naegeles’ Rule, which should be the CORRECT answer of Nurse Margie? A. November 14, 2017 B. October 14, 2017 C. November 19, 2017 D. October 19, 2017 35. Nurse Jubel Explained the chronological order of the growth and development of the fetus as it occurs in pregnancy which is the following __________. A. Ovum, zygote, morula, embryo, fetus, infant B. Morula, zygote, ovum, fetus, embryo, infant C. Morula, ovum, embryo, zygote, fetus, infant D. Zygote, ovum, morula, embryo, fetus, infant Situation 8- Nurse Korinna attends to Patient Cha Hin who is three months pregnant when a pelvic sonogram was conducted on her revealing the fetus’ weak cardiac pulsation. Nurse Korinna advised the patient to have a follow up visit to their clinic after a week but it was only after two weeks that the patient returned when she started to suffer from severe abdominal pains. Upon examination, the doctor found out that there was a dead fetus in her womb. The patient underwent hysterectomy and as a result, she had no more chance to bear a child. 36. Cha Hin filed legal charges against all people concerned regarding the outcome of the procedure done to redress the damages caused by the procedure. Who among the following will be accountable to the patient? A. None, all members of the health care team performed their professional duties on the patient. B. Only Dr. A but not the nurse because the latter was just following orders from the physician. C. Dr. A and the nurse because of their failure to perform their perspective duties with diligence and care. D. Dr. A and the hospital administrator because of command responsibilities on the treatment and care to the patient. 37. Under the situation, if the physician and the nurse are liable over the consequence of the treatment and care of the patient, what applicable legal doctrine will this be? A. Respondeat Superior B. Captain of Ship Doctrine C. Patient’s Proximate Negligence D. Res Ipsa Loquitor 38. If the nurse is called to testify on the alleged surgical procedure performed to the patient to determine whether there was lack of necessary care and diligence, the nurse should testify only on matters which are ________. A. Within her personal knowledge B. Documented in the chart C. Advised by her lawyer D. Being asked by the court 39. Medical records have legal implications. In as much as the nurse failed to chart the discharge instructions, what principle in records management was violated? A. “If it was not documented, it was not done.” B. “Completion of chart should be within 48 hours.” C. “No document, no discharge.” D. “Not all documented data are true.” 40. Hospital A practices clinical pharmacy. Physician writes the order of medications, pharmacist prepares it and the nurse administers it. Who then will be liable for any drug overdose administered intravenously by the nurse? A. Pharmacist B. Nurse and Physician C. Nurse D. nurse and pharmacist Situation 9- Joseph, 3 years old, who underwent ventricular septal defect repair, is placed on a maintenance dosage of digoxin (Lanoxin) elixir. Nurse Hannah, complete with the knowledge of the disease, is assigned to him. 41. The dosage is 0.07 mg/kg/day, and the client’s weight is 7.2 kg. The physician orders the Digoxin to be given twice daily. How much Digoxin should Nurse Hannah prepare to administer at each dose? A. 2.5 mg B. 0.5 mg C. 0.37 mg D. 0.25 mg 42. Nurse Rita provides home care instructions to the parents of Joseph regarding the procedure for the administration of digoxin (Lanoxin). Which statement, if made by the parent, indicated the need for further instructions? A. “If the child vomits after medication administration, I will repeat the dose.” B. “If more than one dose is missed, I will call the physician.” C. “I will take the child’s pulse before administering the medication.” D. “I will not mix the medication with any food and drinks.” 43. Which of the following instructions about ORAL pediatric medications is TRUE as these interfere with milk and milk products or food eaten by young children? Oral medication should be given_____________. A. With meals always B. On an empty stomach C. 1⁄2 hour after meals D. With the night time formula 44. Joseph has a blood pressure of 92/78; resting pulse of 60; respirations 28 and a potassium level of 4.8 mEg/L. He is irritable and has vomited twice since the morning dose of digoxin. Which finding is most indicative of digoxin toxicity? A. Vomiting B. Lethargy C. Bradycardia D. Irritability 45. Considering Joseph’s age, which of the following is the BEST approach by the nurse when administering medication? A. “You will feel better if you take your medication.” B. “Would you like to take your medicine from a spoon or a cup?” C. “Do you want to take this pretty red medicine?” D. This is your medicine and you must take it all right now.” Situation 10- Hani, a 5- year- old child, is admitted to the hospital for abdominal pain. The mother reports that the child has been pale, tires easily and has hematomas in the arms and legs. On physical examination, lymphadenopathy and hepatosplenomegaly are noted. Diagnostic studies are being performed on the child because acute lymphocytic leukemia is suspected. 46. Which of the following procedures will confirm this diagnosis? A. A lumbar puncture B. A platelet count C. Bone marrow biopsy D. White blood cell count 47. Based on the instructions of the nurse, which of the following activities should NOT be done by the parents in monitoring possible infection on Hani? A. Taking the rectal temperature daily B. Inspecting the skin daily for redness C. Inspecting the mouth daily for lesions D. Performing proper hand washing techniques 3 | Page
48. What is the PRIMARY effect of leukemia on the bone marrow? A. a selective reduction in the number of neutrophils B. Leucopenia, thrombocytopenia, and anemia C. The crowding out of normal cells on the site D. Proliferation of cells producing blood components 49. The patient’s parents asked why her child has hematomas and anemia. Which of the following should be the explanation of Nurse Jean Ralffio? A. “Hematomas and anemia are related to the child’s inactivity.” B. “All blood cells are made in the bone marrow. Hematomas and anemia are due to decreased RBC and platelet count.” C. “Hematomas and anemia are indicative that the end is near.” D. “the anemia is because the child hasn’t been eating well; the hematomas are from the multiple needle sticks.” 50. Patients Hani is not expected to survive. Hani says to her mother, “Will you take care of me when I am dead the way you do now?” the child’s mother asks Nurse Jean Ralffio how to answer her child. The nurse’s response should be based on which of the following understanding of the child’s behaviour. A. “Children of this age do not understand the finality of death.” B. “The child is denying that he has a terminal illness.” C. “Most 5-year-old children have a great fear of mutilation.” D. “the child may be having visual and auditory hallucinations.” Situation 11- a 13-year-old- girl named Zelda tells the nurse at the pediatric clinic that she took a pregnancy test and it was positive. She tells the nurse that her grandfather, with whom she, her younger siblings, and her mother live, has repeatedly molested her for the past 3 years. When the nurse asks the girl if she has told this to anyone, she replies: “Yes, my mother.” 51. As the nurse’s legal responsibility, which is the APPROPRIATE agency should she notify FIRST? A. City Health Office to do a vaginal examination to confirm the pregnancy B. DSWD for notifying the girl’s mother about the pregnancy test positive result. C. Board members of Child Protective Services for proper intervention D. Philippine National Police concerning a possible sex crime 52. If Zelda is really a victim of incest and the agency opts that she be admitted in the hospital, where should she be placed? A. With an older friendly child B. In a room near the nurse’s station C. With another 5 year old D. In a private room 53. The abusive parent usually manifests one of the following characteristics EXCEPT________ A. History of severe mental illness B. History of drug abuse C. Belongs to low-income group D. Low tolerance for frustration 54. When a patient, who allegedly has been sexually abused, the nurse should be aware that legal proceedings may be necessary. Because of this possibility, which of the following actions is MOST important to be done by the nurse? A. Determining if there are other injuries such as bruises and hematomas. B. Asking the parents for their approval for diagnostic examinations for the child. C. Assessing the child’s physical, intellectual and emotional developmental levels. D. Documenting physical findings and interactions during admission. 55. What typical assessment findings are observed to a patient who is a victim of sexual abuse A. Recurrent UTI B. Fracture and bruises C. Enuresis D. Failure to thrive syndrome Situation 12- Nurse Von is assigned at the Under Five Clinic. Mostly of her patients are infants, so she took the opportunity to have a mother’s class on the care of infants. 56. Which of the following will Nurse Von EMPHASIZE regarding the importance of play during infancy? Play enhances _______ development. A. Cognitive B. Emotional C. Physical D. Social 57. Which among the infants would show signs that he/she is experiencing maternal deprivation? A. Hyperactive B. Overweight C. prone to illness D. responsive to stimuli 58. What should Nurse Von include in the accident prevention teaching plan for a mother with 4-month-old infant? A. Keep crib rails up to the highest position. B. Cover electric outlets with safety plugs. C. Remove poisonous substances from low areas. D. Remove small objects from the floor. 59. When teaching a mother how to prevent accidents while caring for her 6-month-old infant, Nurse Von should emphasize that at this age, the infant can already do which of the following developmental milestone? A. Stand while holding on to furniture. B. Crawl short distances. C. Roll over from back to abdomen. D. Sit up without assistance. 60. Nurse Von assesses the oral cavity of a 6-month-old child and finds out that the tooth that buds first is the __________. A. Upper molars B. Lower central incisor C. Canines D. Lower molars Situation 13- Nurse Karl is caring for a mother- infant dyad. The mother has just given birth to a baby boy two days ago. Today, the charge nurse us doing a chart audit to determine whether the nursing process was properly done from prenatal to postnatal periods. The laboratory results of the mother and baby boy are shown below. Mrs. Gloria Lim: Prenatal Laboratory Results Type: RH Rubella Titer RPR/VDRL HB Sag HIV Hgb/Hct PKU _________ __________ __________ _______ _____ _______ _______ A Negative 1: 8 Negative Negative Negative 11/33 Negative Baby Boy Lim: Day 2 of Life Laboratory Test Results Blood Glucose Total Bilirubin Blood Type HCT ____________ ___________ _________ ____ 50 10 mg 1 Negative 50 61. Using the chart data, which nursing intervention was CORRECTLY done by Nurse Karl for Mrs. Gloria Lim? A. Rubella vaccination B. Rhogam injection C. Neonatal 50% glucose infusion D. Maternal blood transfusion 62. Nurse Karl charted an IMPORTANT plan of care for Mrs. Lim. He indicated in her charting that the patient should report immediately signs and symptoms of a virus-causing- disease which may affect the cardiovascular system of the fetus during which of the period of pregnancy? A. First month B. Third month C. Second Month D. Fourth Month 63. Looking at the medication sheet, the charge nurse noted that Nurse Karl used the CORRECT ROUTE in the administration of the vaccine, which was_______________. A. Rectal 4 | Page