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TOP RANK REVIEW ACADEMY, INC. Page 1 | 7 RECALLS EXAMINATION 1 NURSING PRACTICE II CARE OF HEALTHY / AT RISK MOTHER CHILD NOV 2024 Philippine Nurse Licensure Examination Review Situation: Pregnancy is a dangerous milestone. Nurse Jeara intends to lessen pregnancy complications. 1. Nurse Jeara is evaluating a pregnant patient diagnosed with abruptio placentae. Which symptoms should she anticipate observing? Select all that apply. i. Uterine irritability ii. Uterine tenderness iii. Painless vaginal bleeding iv. Abdominal and low back pain v. Strong and frequent contractions vi. Nonreassuring fetal heart rate patterns A. I, II, III,IV B. I, II, IV, V C. I, II, IV, VI D. II, III, IV 2. While caring for a client in the active stage of labor, she observes a late deceleration on the fetal monitor strip. What immediate action should she plan? A. Document the findings. B. Prepare for immediate birth. C. Increase the rate of oxytocin infusion. D. Administer oxygen to the client via face mask. 3.She is preparing to assess a client in her second trimester of pregnancy. When measuring fundal height, what should she expect regarding its relationship to gestational age? A. It is less than gestational age. B. It corresponds with gestational age. C. It is greater than gestational age. D. It has no correlation with gestational age. 4.A pregnant client informs her that she noticed wetness on her peripad and discovered some clear fluid. Upon inspecting the perineum, Jeara observes the umbilical cord. What should the nurse do immediately? A. Monitor the fetal heart rate. B. Notify the primary health care provider. C. Transfer the client to the delivery room. D. Place the client in the Trendelenburg position. 5.She is giving advice to a patient in the third trimester of pregnancy regarding heartburn management techniques. Which instructions should she give to the patient? A. Sip some hot tea or milk. B. Make use of sodium-containing antacids. C. Consume fatty meals only once a day in the morning. D. Rather than eating short, regular meals, eat three big meals a day. 6.She is caring for a client in labor. She determines that the client is beginning in the 2nd stage of labor when which of the following assessments is noted? A. The client begins to expel clear vaginal fluid B. The contractions are regular C. The membranes have ruptured D. The cervix is dilated completely 7.Nurse Jessa is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which of the following actions is most appropriate? A. Document the findings and tell the mother that the monitor indicates fetal well-being B. Take the mothers vital signs and tell the mother that bed rest is required to conserve oxygen. C. Notify the physician or nurse mid-wife of the findings. D. Reposition the mother and check the monitor for changes in the fetal tracing 8.She is caring for a client with abruptio placenta and is monitoring the client for disseminated intravascular coagulopathy. Which assessment finding is least likely to be associated with disseminated intravascular coagulation? A. Swelling of the calf in one leg B. Prolonged clotting times C. Decreased platelet count D. Petechiae, oozing from injection sites, and hematuria 9.A client is admitted to the birthing suite in early active labor. The priority nursing intervention on admission of this client would be: A. Auscultating the fetal heart B. Taking an obstetric history C. Asking the client when she last ate D. Ascertaining whether the membranes were ruptured 10.A postpartum patient was in labor for 30 hours and had ruptured membranes for 24 hours. For which of the following would nurse Jessa be alert? A. Endometritis B. Endometriosis C. Salpingitis D. Pelvic thrombophlebitis 11.A prenatal client is suspected of having iron deficiency anemia. During the assessment, which finding should the nurse he expect to observe as a result of this condition? A. Dehydration B. Overhydration C. A high hematocrit level D. A low hemoglobin level 12.A prenatal client has been diagnosed with a vaginal infection caused by Candida albicans. What should he expect to observe during the assessment? A. Costovertebral angle pain B. No observable signs C. Pain, itching, and vaginal discharge D. Proteinuria, hematuria, and hypertension 13. For a client starting oral medication, he gives instructions regarding the use of oral contraceptives. Which of the client's statements suggests that more instruction is necessary? A. "Every day at the same time, I will take one pill." B. "I have to take the missed pill as soon as I remember it if I miss it." C. "After I begin using these, I won't need to use any other birth control methods.” D. “I will take both pills as soon as I remember if I had missed two pills, ,and then two tablets the following day.” 14.A client with a family history of heart disease presents to the primary health care provider's office with a request to start oral contraceptive therapy for birth control. What important topic should Nurse Tommy ask the client about next? A. Smoking B. Regular exercise C. Low cholesterol diet D. Alternative methods of contraception 15.Nurse Tommy teaches a pregnant client to perform Kegel exercises. Which statement by the client indicates an understanding of the purpose of these types of exercises? A. “The exercises will help reduce backache.” B. “The exercises will help prevent ankle edema.” C. “The exercises will help strengthen the pelvic floor.” D. “The exercises will help prevent urinary tract infections.”
TOP RANK REVIEW ACADEMY, INC. Page 2 | 7 16.Nurse Dan is caring for a postpartum client. He should suspect endometritis if which of the following is observed? A. Breast engorgement B. Elevated white blood cell count C. Lochia rubra on the second day postpartum D. Fever over 38° C (100.4° F) starting 2 days postpartum 17.He gives instructions to a new mother who is preparing to breastfeed her newborn. While observing the first breastfeeding session, he determines that further teaching is needed if the new mother performs which technique? A. Turns the newborn onto his side, facing the mother B. Tilts up the nipple or squeezes the areola, pushing it into the newborn's mouth C. Draws the newborn further onto the breast when the newborn opens his mouth D. Inserts a clean finger into the side of the newborn's mouth to break the suction before removing the newborn from the breast 18.A breastfeeding client, ten days postpartum, calls the postpartum unit, reporting a painful, reddened breast and a fever. Considering the client's symptoms, what guidance should he provide? A. "Continue breastfeeding from the unaffected breast only." B. "Cease breastfeeding as it's likely you have an infection." C. "Contact your healthcare provider as medication may be necessary." D. "Continue with breastfeeding as this reaction is typical in breastfeeding mothers." 19.When a breastfeeding mother mentions experiencing nipple soreness, nurse Dan offers guidance on alleviating the discomfort. Which statement from the mother demonstrates comprehension of the instructions? A. “I should refrain from changing breastfeeding positions to toughen the nipple.” B. “I should temporarily halt nursing to give the nipples time to heal.” C. “I should breastfeed less often and replace some feedings with bottle feeding until the nipples feel better.” D. “I should position my baby so her ear, shoulder, and hip are aligned and her stomach is against me.” 20.A new breastfeeding mother, suffering from breast engorgement, receives guidance on managing the condition. Which statement from the mother indicates to nurse Dan that she comprehends the strategies for alleviating discomfort from breast engorgement? A. "I will breastfeed using just one breast." B. "I will use cold compresses on my breasts." C. "I will refrain from wearing a bra while my breasts are engorged." D. "I will massage my breasts before feeding to stimulate milk letdown." 21.During an assessment of a mother who recently gave birth to a healthy newborn, where should the nurse anticipate finding the fundus positioned? A. On the right side of the abdomen B. Level with the umbilicus C. Above the umbilicus D. One finger's breadth above the symphysis pubis 21.A new mother received an intramuscular injection of methylergonovine maleate following delivery. The nurse comprehends that this medication was administered for what purpose? A. To decrease uterine contractions. B. To prevent postpartum hemorrhage. C. To sustain normal blood pressure. D. To diminish the amount of lochia drainage 22.A new mother received an intramuscular injection of methylergonovine maleate following delivery. The nurse comprehends that this medication was administered for what purpose? A. To decrease uterine contractions. B. To prevent postpartum hemorrhage. C. To sustain normal blood pressure. D. To diminish the amount of lochia drainage 23.Methylergonovine maleate is prescribed for a woman who has just delivered a healthy newborn. Which is the priority assessment to complete before administering the medication? A. Lochia B. Uterine tone C. Blood pressure D. Deep tendon reflexes 24.A registered nurse is a preceptor for a new nurse and is observing the new nurse organize the client assignments and prioritize daily tasks. The registered nurse should intervene if the new nurse implements which action? A. Provides times for staff meals B. Gathers the supplies needed for a task A. Combines all tasks for clients in one list B. Documents task completions at the end of the day 25..When the nurse manager encourages staff to provide input in the decisionmaking-process, which leadership style is being demonstrated? A. Autocratic B. Situational C. Democratic D. Laissez-faire 26.She is educating a pregnant client about the physiological impacts and hormonal shifts during pregnancy. What information should she convey regarding the function of estrogen? A. Estrogen maintains the uterine lining to facilitate implantation. B. Estrogen boosts glucose metabolism and converts glucose into fat. C. Estrogen inhibits the regression of the corpus luteum, maintaining progesterone production until the placenta forms. D. Estrogen stimulates uterine growth to create a conducive environment for the fetus and primes the breasts for lactation. 27.She is preparing to conduct a class on testicular self- examination (TSE) at a local high school, should incorporate which guidance for the attendees? A. Conduct the self-examination every two months. B. Perform the self-examination following a cold shower. C. Anticipate slight discomfort during the self-examination. D. Gently roll the testicle between the thumb and forefinger. 28.She is teaching a group of females how to prevent pelvic inflammatory disease (PID). What instruction should the nurse include? A. To douche monthly B. To avoid unprotected intercourse C. To use only ultra-low dose oral contraceptive pills D. To consult with a gynecologist regarding the placement of an intrauterine device (IUD) 29.She is providing discharge teaching to a client after a vasectomy. Which statement by the client indicates the need for further teaching? A. “I can use a scrotal support if I need to.” B. “I don’t need to practice birth control any longer.” C. “I can resume sexual intercourse whenever I want.” D. “I can use an ice bag and take an analgesic for pain or swelling.” 30.She asks a student to identify risk factors for and methods of preventing prostate cancer. Which statement by the student indicates the need for further teaching? A. “Smoking increases the risk for this type of cancer.” B. “A high-fat diet will assist in preventing this type of cancer.” C. “A history of a sexually transmitted infection is a risk for this disease.” D. “Men more than 50 years old should be monitored with a yearly digital rectal exam.” 31.On assessment of a newborn being admitted to the nursery, Nurse Angel palpates the anterior fontanel and notes that it feels soft. She determines that this finding indicates which condition? A. Dehydration B. A normal finding C. Increased intracranial pressure D. Decreased intracranial pressure 32.Nurse Angel is assessing a postterm infant. Which physical characteristic should the nurse expect to observe? A. Peeling skin B. Smooth soles without creases C. Lanugo covering the entire body D. Thick layer of vernix covering the body 33.A postterm infant delivered vaginally is showing signs of tachypnea, grunting, retractions, and nasal flaring. Angel interprets these findings as indicative of which condition? A. Hypoglycemia B. Respiratory distress syndrome
TOP RANK REVIEW ACADEMY, INC. Page 3 | 7 C. Meconium aspiration syndrome D. Transient tachypnea of the newborn 34.The nurse is evaluating a 3-day-old preterm neonate diagnosed with respiratory distress syndrome (RDS). Which assessment finding suggests improvement in the neonate's respiratory condition? A. Edema of the hands and feet B. Urine output of 3 mL/kg/hour C. Presence of a systolic murmur D. Respiratory rate ranging from 60 to 70 breaths per minute 35.A newborn baby whose mother is Rh negative is told to be admitted to the nursery by the nurse. Which move should the Angel make in preparation for the infant's arrival? A. Determine the blood type of the newborn and direct Coombs results. B. Acquire from the blood bank the supplies required for an exchange transfusion. C. Request the installation of a phototherapy unit by calling the maintenance department to be taken to the nursery. D. To avoid isoimmunization, get a vial of vitamin K from the pharmacy and be ready to give an injection. 36.A newborn baby has been diagnosed with imperforate anus. How should Nurse Adolf explain this condition to the parents? A. The occurrence of fecal incontinence B. Inadequate development of the anus C. Difficulty passing infrequent, dry stools D. Folding of a portion of the intestine into the lower bowel 37.Which nursing assessment findings indicate normal vital signs in a newborn infant? A. Pulse, 112; respiratory rate, 24 B. Pulse, 124; respiratory rate, 28 C. Pulse, 144; respiratory rate, 48 D. Pulse, 164; respiratory rate, 55 38.Nurse Adolf teaches nursing students about mumps. Which clinical manifestation will the specialist identify as the most common complication of this disease? A. Pain B. Nuchal rigidity C. Impaired hearing D. A red swollen testicle 39.Nurse Adolf is assigned to care for an infant on the first postoperative day after a surgical repair of a cleft lip. Which nursing intervention is appropriate when caring for this child’s surgical incision? A. Rinsing the incision with sterile water after feeding B. Cleaning the incision only when serous exudate forms C. Rubbing the incision gently with a sterile cotton-tipped swab D. Replacing the Logan bar carefully after cleaning the incision 40.He is caring for a child diagnosed with Reye’s syndrome. He monitors for manifestations of which condition associated with this syndrome? A. Protein in the urine B. Symptoms of hyperglycemia C. Increased intracranial pressure D. A history of a staphylococcus infection 41.A 10-year-old child is newly diagnosed with type 1 diabetes mellitus. The nurse is planning for home care with the child and the family and determines that which is an age-appropriate activity for health maintenance? A. Administering insulin drawn up by an adult B. Self-administering insulin with adult supervision C. Making independent decisions with regard to sliding-scale coverage of insulin D. Having an adult assist in the self-administration of insulin and glucose monitoring 42.A home care nurse is providing instructions to the mother of a toddler regarding safety measures in the home to prevent an accidental burn injury. Which statement by the mother indicates a need for further instruction? A. “I need to use the back burners for cooking.” B. “I need to remain in the kitchen when I prepare meals.” C. “I need to be sure to place my cup of coffee on the counter.” D. “I need to turn pot handles inward and to the middle of the stove.” 43.The nurse is reviewing the results of the rubella screening (titer) with a pregnant client. The test results are positive, and the client asks if it is safe for her toddler to receive the vaccine. Which response by the nurse is most appropriate? A. “Most children do not receive the vaccine until they are 5 years of age.” B. “You are still susceptible to rubella, so your toddler should receive the vaccine.” C. “It is not advised for children of pregnant women to be vaccinated during their mother’s pregnancy.” D. “Your titer supports your immunity to rubella, and it is safe for your toddler to receive the vaccine.” 44.The nurse is assigned to care for a hospitalized toddler. Which measure should the nurse plan to implement as the highest priority of care? A. Providing a consistent caregiver B. Protecting the toddler from injury C. Adapting the toddler to the hospital routine D. Allowing the toddler to participate in play and diversional activities 45.A mother of a 3-year-old child asks the nurse what personal and social developmental milestones she can expect to see in her child. The nurse should tell the mother to expect which findings? Select all that apply. i.Begins problem-solving ii.Exhibits sexual curiosity iii.May begin to masturbate iv.Notices gender differences v.Develops a sense of initiative vi.Develops positive self-esteem through skill acquisition A. I, II, III B. II, IV C. II, III, IV D. II, III, V 46.What action should you take before performing a venipuncture to start continuous intravenous (IV) therapy? A. Apply a cool compress to the area. B. Inspect the IV solution and check the expiration date. C. Secure a padded armboard above the IV site. D. Apply a tourniquet below the venipuncture site. 47.The doctor prescribes acetaminophen liquid 450 mg orally every 4 hours PRN for pain. The medication label reads 160 mg/5 mL. You prepare how many milliliters (mL) to administer one dose? A. 12 ML B. 15ML C. 13ML D. 14ML 48.You are sending an arterial blood gas (ABG) specimen to the laboratory for analysis. What information should be included on the laboratory requisition? Select all that apply. i.Ventilator settings ii.List of client allergies iii.Client’s temperature iv.Date and time the specimen was drawn v.Any supplemental oxygen the client is receiving vi.Extremity from which the specimen was obtained A. I, II, III B. I, II, IV, V C. I, III, IV, VI D. I, III, IV, V 49.Which arterial blood gas (ABG) values should you anticipate in the client with a nasogastric tube attached to continuous suction? A. pH 7.25, Paco2 55, HCO3 24 B. pH 7.30, Paco2 38, HCO3 20 C. pH 7.48, Paco2 30, HCO3 23 D. pH 7.49, Paco2 38, HCO3 30 50.For ensuring client safety, which assessment should you prioritize before transitioning a client from liquid to solid food? A. Bowel sounds B. Chewing ability C. Current appetite D. Food preferences 51.The burn initially affected the upper half of the client’s anterior torso, and there were circumferential burns to the lower half of both of the arms. The client’s clothes caught on fire, and the client ran causing subsequent burn injuries to the entire face (anterior half of the head), and the upper half of the posterior torso. Using the rule of nines, the extent of the burn injury would be what percent? A. 27% B. 48.5% C. 54% D. 31.5%
TOP RANK REVIEW ACADEMY, INC. Page 4 | 7 52.You are anticipating rapid fluid replacement therapy for the patient. With the previously identified percentage of burn injury, how much fluid should be administered over the first 24 hours if the patient weighs 72 kg? A. 9,072 mL B. 7,776 mL C. 13,968 mL D. 15,552 Ml 53.A client who is brought to the emergency department has experienced a burn covering greater than 25% of his total body surface area (TBSA). When reviewing the laboratory results drawn on the client, which value should you most likely expect to note? A. Hematocrit 65% (0.65) B. Albumin 4.0 g/dL (40 g/L) C. Sodium 140 mEq/L (140 mmol/L) D. White blood cell (WBC) count 6000 mm3 (6 × 109/L) 54.The client is scheduled for hydrotherapy for a burn dressing change. Which action should you take to ensure that the client is comfortable during the procedure? A. Ensure that the client is appropriately dressed. B. Administer an opioid analgesic 30 to 60 minutes before therapy. C. Schedule the therapy at a time when the client generally takes a nap. D. Assign an unlicensed assistive personnel (UAP) to stay with the client during the procedure. 55.He receives a prescription for a regular diet. Which is the best meal for you to provide to the client to promote wound healing? A. Peanut butter and jelly sandwich, apple, tea B. Chicken breast, broccoli, strawberries, milk C. Veal chop, boiled potatoes, Jell-O, orange juice D. Pasta with tomato sauce, garlic bread, ginger ale 56.She was asked by a first-time mom how she can provide and meet the needs of her 3- year old infant. She tries to fill the crib with toys, but her infant is not responding to it very well. What should she do? A. Place large, colorful teddy bears around the infant’s crib B. Provide safe and washable toys such as pacifier C. Give brightly-colored building blocks to the infant D. Give her infant a rattle for her to shake 57.Toddlers exhibit signs of readiness for toilet training. Which among the following are not included as its criteria? A. Child is able to stay dry for 2 hours B. Child is waking up dry from a nap C. Child is able to sit, squat, and walk D. Child is able to wear clothing by themselves 58.This type of attachment or complex is present among pre- school children wherein the strong emotional attachment of a preschool boy is present towards the mother, and they usually tend to hate the father. A. Electra complex B. Oedipus complex C. Persephone complex D. Adolphus complex 59.The nurse observes an 8-year old child for any signs of psychosexual development. What should they expect from this stage? A. a time in which children’s libido appears to be diverted into concrete thinking B. at the age where they want to fulfill their intimate desires C. at the age where they are ready to learn how to defecate by themselves D. at the time where they will explore their own genitals 60.The nurse understands that Freud's phallic stage of psychosexual development, which compares with Erikson's psychosocial phase of initiative versus guilt, is seen best at: A. Adolescence B. 6 to 12 years C. 3 to 5 1/2 years D. Birth to 1 year 61.The nurse understands that problems with dependence versus independence develop during the sage of growth and development known as: A. Infancy B. School age C. Toddlerhood D. Preschool age 62.When planning to teach about the stages of growth and development, what stage does the nurse indicate as basically concerned with role identifications? A. Oral stage B. Genital stage C. Oedipal stage D. Latency stage 63.The nurse incorporates play in interactions with preschool- aged children, recognizing that play is essential for their emotional development in the areas of: A. Projection B. Introjection C. Competition D. Independence 64.The nurse understands that the resolution of the Oedipus complex occurs when the child: A. Rejects the parent of the same sex B. Adopts behaviors of both parents C. Identifies with the parent of the same sex D. Identifies with the parent of the opposite sex 65.Surgery can be a very traumatic even for a child. The nurse, when performing preoperative preparation, knows that according to Piaget's stages of cognitive development, children will experience the greatest fear during the: A. Sensorimotor stage B. Preoperational stage C. Formal operational stage D. Concrete operational stage 66.Nurse Nina further assesses May. When BP was taken at 11:00 am, the reading was at 140/80 mmHg. She knows that the physician may confirm that May is developing PIH when which criterion is satisfied? A. BP is at 130/90 mmHg at 12nn. B. A BP reading is read to be 140/90 at 1:30 pm C. 30/15 mmHg is added to the baseline BP at 7:00 pm. D. BP is at 90/60 mmHg at 11:00 pm 67.May asks Nurse Nina to explain the reason why PIH occurs. Nurse Nina's most appropriate answer would be: A. "An increase in blood volume to support the growing child caused an increased pressure in the arteries causing damage to the walls. This led to the blood vessels in the body to suddenly tighten up or get narrower, thus causing the blood pressure to shoot up." B. "Blood volume is increased by 40-50% in pregnancy, which usually peaks at the 2nd trimester due to an increase in plasma volume. That caused an increase in pressure in the endothelial lining of the arteries eventually leading to vasospasm. Hypertension occurs due to the narrowing of the blood vessels due to the spasms." C. "The precise etiology revolves around aberrations in vascular homeostasis, with dysregulation of endothelial function and vascular tone modulation being paramount. This intricate cascade encompasses the intricate dance between vasoconstriction-promoting factors and vasodilation-mediating substances, leading to an imbalance favoring heightened vascular resistance and augmented systemic arterial pressure." D. "I am not sure if I am allowed to give details about that diagnosis. I will ask your physician to explain it to you instead." 68.The nurse further assesses May for any other signs while she interviews her in the clinic as she documents the findings in May's chart. Which statement from May would she record as possible evidence that May is developing pre-eclampsia instead? A. "I'm struggling to slip on my bedroom slippers because my feet are so puffy at night." B. "My mom taught me a lot of things about being pregnant, but she never warned me that I would always feel so tired." C. "I've been having the desire to really take care of how I look like these past few weeks." D. "The puffy feet are tolerable, but the swollen hands and wrists are not."