Tiêu đề RECALLS 8 (NP2) - STUDENT COPY ✅

RECALLS EXAMINATION 8 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: Anna and Kevin, a new couple, sought information on various contraception methods at the Barangay Health Center as they were unprepared emotionally and financially for the responsibility. 1. You are a newly hired nurse. Anna and Kevin want to know what you should know about selecting a contraceptive method. When selecting the best contraceptive method, what should be the top priority to consider? A. The culture of the couple B. The acceptance of the couple C. The expert opinion of any medical related personnel D. The religious beliefs of the couple 2. Last May 23, 2024, Anna experienced a 0.5-degree Fahrenheit drop in her temperature, followed by a 1.1-degree increase the next day. She asked when she should avoid coitus? A. May 22, 2024 B. May 23,24,25 2024 C. May 24,25,26, and 27 2024 D. May 24 to June 10, 2024 3. You are a dedicated nurse who promptly conducts rounds right after receiving patient handover. As you approach room 304, you overhear a couple arguing about the duration of the lactational amenorrhea method. The woman insists they can only use it for a specific period, but the husband argues that they can use it for as long as they want. As a competent and dedicated nurse, you know that LAM is only effective during ____? A. First 3 months B. First 6 months C. 6 months D. 3 months 4. A woman recently treated for toxic shock syndrome has occasional intercourse and uses over-the-counter protection. Based on her history, what contraceptive method should she and her partner avoid? A. Cervical Cap B. Condom C. Vaginal film D. Vaginal Sheath 5. Nurses, licensed nurse-midwives, and other advanced practice nurses have the knowledge and skills to help women make well-informed decisions about contraception. An interdisciplinary approach should ensure that the woman's social, cultural, and interpersonal needs are met. What should be the nurse's first step when meeting a new client to discuss contraception? A. Obtain the information/data about the frequency of coitus. B. Determine the woman’s level of knowledge about contraception and commitment to any particular method. C. Assess the woman’s willingness to touch her genitals and cervical mucus. D. Evaluate the woman’s contraceptive life plan. Situation: Sexually transmitted infections (STIs) have a significant impact on sexual and reproductive health globally. More than 1 million curable STIs are acquired each day. In 2020, the World Health Organization (WHO) reported an estimated 374 million new infections of 4 common STIs: chlamydia (129 million), gonorrhea (82 million), syphilis (7.1 million), and trichomoniasis (156 million). In the Philippines, there is a high prevalence of STIs among sex workers, with the prevalence rate of selected STIs, predominantly chlamydial infections, reaching more than 40%. 6. The nurse in a pediatric clinic is caring for a 10-year-old girl who has been diagnosed with gonorrhea. Which of the following actions is appropriate for the nurse to take? A. Report the girl’s medical findings to child protective services. B. Engage in a discussion with the girl about the importance of avoiding future sexual encounters. C. Question the mother about her daughter’s menstrual history. D. Notify the physician so the child can be admitted to the hospital. 7. A woman has been diagnosed with pelvic inflammatory disease Which of the following organisms is the most likely causative agent? A. Herpesviridae. B. Candida albicans. C. Neisseria gonorrhoeae. D. Treponema pallidum. 8. A patient has been diagnosed with pubic lice. Which of the following signs and symptoms would the nurse expect to see? A. Macular rash on the labia B. Pruritus C. Hyperthermia D. Foul-smelling discharge 9. A female client has been diagnosed with primary syphilis. Which of the following manifestations would the nurse expect to see? A. Cluster of vesicles B. Painless lesion. C. Macular rash D. Foul smelling discharge 10. A gravid, married client, 24 weeks' gestation, is found to have bacterial vaginosis. In order to address the issue, her physician has prescribed metronidazole (Flagyl). Which of the following educational information is important for the nurse to provide the woman at this time? A. The woman must be careful to observe for signs of preterm labor. B. The woman must advise her partner to seek therapy as soon as possible. C. The main side effect of the medicine is a copious vaginal discharge. D. A repeat culture should be taken two weeks after completing the therapy. Situation: Jennie, a 26-year-old pregnant woman, enters the labor and delivery room, stating that she thinks she is in labor. 1 | Page
11. Staku, the new nurse in the OB ward, is evaluating a client who claims to be in labor. Which findings would help Staku confirm the client’s belief? A. She is contracting q 5min x 60 sec. B. Her cervix has dilated from 2 to 4 cm. C. Her membranes have ruptured D. The fetal head is engaged. 12. A client who is in labor (G2 P1001) was admitted one hour ago at 2cm dilated and 50% effaced. At the time of admission, she was talkative and excited. However, in the past 10 minutes, she has become more severe, closing her eyes and breathing rapidly with each contraction. What is the accurate nursing assessment of the situation? A. The client had poor childbirth education prior to labor. B. The client is exhibiting an expected behavior for labor. C. The client is becoming hypoxic and hypercapnic. D. The client needs her alpha-fetoprotein levels checked. 13. During the latent phase of labor, when should the nurse assess the fetal heart pattern of a low-risk woman, G1 P0000? SATA 1 After vaginal exams. 2 Before administration of analgesics. 3 Periodically at the end of a contraction. 4 Every ten minutes. 5 Before ambulating A. 1,2,5 B. 2,3,4,5 C. 2,4,5 D. 1,2,3,5 14. The newly admitted client is shouting and complaining due to severe back labor. Which of the following nursing interventions would be most helpful to the condition of the client? A. Assist the client with childbirth breathing/deep breathing. B. Encourage mother to have an epidural anesthesia. C. Provide direct sacral pressure. D. Use a hydrotherapy tub. 15. As the nurses were busy evaluating a client in labor, Jhoanna left the nurse station. At 8:00 p.m., a pregnant client at full term called the nurse station to ask whether she was in labor. The nurse determined that the client was likely in labor after the client mentioned: A. “At 6:00 p.m., the contractions were about 5 mins apart. Now, they’re about 7 minutes apart.” B. “I took a walk at 6:00 p.m., and now I talk through my contractions easier than I could then.” C. “ I took a shower about a half hour ago. The contractions seem to hurt more since I finished.” D. “ I had some tightening in my belly late this afternoon, and I still feel it after waking up from my 2-hour nap” Situation: A patient, 32 weeks pregnant experiencing severe headache, is admitted to the hospital with pre-eclampsia. 16. Nurse Colet would anticipate that the primary health care provider would request tests to evaluate the fetus for which of the following? A. Severely low red blood cells B. Hypoprothrombinemia C. Craniosynostosis D. Intrauterine growth restriction 17. Nurse Colet is assessing for clonus. Which of the following actions should nurse Colet perform? A. Strike the woman’s patellar tendon B. Palpate the woman’s ankle C. Dorsiflex the woman’s foot. D. Position the woman’s feet flat on the floor. 18. Nurse Colet assessed the client and found a blood pressure of 170/112, 4+ proteinuria, and a weight gain of 10 pounds over the last two days. Nurse Colet also expected these signs and symptoms to be present. A. Fundal height of 32 cm. B. Papilledema C. Patellar reflexes of +2 D. Nystagmus 19. Nurse Colet is grading a woman’s reflexes. Which of the following grades would indicate reflexes that are slightly hyperreflexic? A. +1 B. +2 C. +3 D. +4 20. A woman who was diagnosed with severe pre-eclampsia also developed HELLP syndrome. Nurse Colet will assess for which of the following signs and symptoms? A. Decreased Level of serum creatinine B. Increased level of serum creatinine C. Hematochezia D. Epigastric Pain Situation: Childhood trauma is the primary factor contributing to mortality in children over the age of 1, as well as a significant contributor to impairment throughout childhood and adolescence. 21. Dr. Robles ask Nurse Colet if which of the following is a physiological effect og immobilization on children? A. Metabolic rate increases B. Increased joint mobility can lead to contractures in a short time. C. Venous stasis can lead to thrombi or emboli formation. D. Bone calcium increases, releasing excess calcium into the body. 22. A young female has recently sustained an injury to her ankle while attending school. Aside from contacting the child's parents, what is the most suitable intervention that needs to be done by Nurse Maloi? A. Apply Ice B. Observe for edema and discoloration. C. Encourage child to assume a position of comfort. D. Obtain consent for parenteral administration of acetaminophen or aspirin. 23. Kristin, who is 10 years old, experienced a fracture in the epiphyseal plate of her right fibula as a result of falling out of a tree. When engaging in a conversation about this injury with her parents, the nurse should consider which of the following factors? A. Healing is usually delayed in this type of fracture. B. Bone growth can be affected by this type of fracture. C. This is an unusual fracture site in young children. D. This type of fracture is inconsistent with a fall. 24. The mother Kristin asked you, what is the advantage of using fiberglass cast instead of plaster of paris cast? A. Cheaper B. Dries easily C. Molds closely to body parts D. Smooth exterior 25. Which of the following would be the most appropriate play activity for a 3 year old child in a spica cast? A. Marbles B. Game of checkers C. Coloring with crayons D. Playing with toy telephone Situation: Baby Alden, a newborn weighing 2.5 kg, was born prematurely at 35 weeks. Within 24 hours of birth, he developed visible jaundice, characterized by a yellowing of his skin and the whites of his eyes. 26. The mother of the baby asked Nurse Colet Which of the following laboratory findings would the nurse expect to see in a baby diagnosed with erythroblastosis fetalis? A. Hematocrit 24%. B. Leukocyte count 45,000 cells/mm3 C. Sodium 125 mEq/L. D. Potassium 5.5 mEq/L. Rationale. 27. A jaundice neonate must have a heel stick to assess bilirubin levels. Which of the following actions should the nurse make during the procedure? A. Cover the foot with an iced wrap for one minute prior to the procedure. B. Avoid puncturing the lateral heel to prevent damaging sensitive structures. C. Blot the site with a dry gauze after rubbing it with an alcohol swab. D. Grasp the calf of the baby during the procedure to prevent injury. 2 | Page
28. A newborn nursery nurse notes that a baby’s body is jaundiced at 36 hours of life. Which of the following nursing interventions will be most therapeutic? A. Maintain a warm ambient environment. B. Have the mother feed the baby frequently. C. Have the mother hold the baby skin to skin. D. Place the baby naked by a closed sunlit window. 29. Nurse Colet noticed that the neonate that is under phototherapy because of elevated bilirubin levels, has loose and green stools. Which of the following is the appropriate action should the nurse take at this time? A. Discontinue the phototherapy B. Notify the MD. C. Obtain the baby’s temperature D. Assess the skin integrity of the baby. 30. A 5-day-old baby receiving phototherapy has the following nursing diagnosis: Risk for fluid volume deficit. Which of the following client outcomes calls for the nurse to keep an eye on the infant? A. 6 saturated diapers in 24 hours. B. Breastfeeds 6 times in 24 hours. C. 12% weight loss since birth. D. Apical heart rate of 176 bpm. 31. Which of the following must Nurse Maloi include in her discharge teaching regarding the vaccine? A. The woman should not become pregnant for at least 4 weeks. B. The woman should pump and dump her breast milk for 1 week. C. The mother must wear a surgical mask when she cares for the baby. D. Passive antibodies transported across the placenta will protect the baby 32. A client who is three days postpartum is asking why she needs to receive the rubella vaccine before being discharged from the hospital. Which of the following explanations should the nurse provide? A. The client’s current obstetric condition is ideal for administering the vaccine. B. The client’s immune system is particularly receptive during the postpartum period. C. The client’s baby will be at a high risk of contracting rubella if the mother does not get vaccinated. D. The client’s insurance will cover the cost of the vaccine if it is administered during the immediate postpartum period. 33. To help prevent infection, Nurse Mikha teaches the postpartum client to do which of the following? A. Use antibiotic ointment on the perineum daily. B. Replace the peripad after each time she urinates. C. Urinate at least every two hours. D. Spray the perineum with povidone-iodine solution after each bathroom visit. 34. A client who is three days postpartum asks the nurse, "When can my husband and I resume sexual activity?" The nurse should advise the couple to wait until which of the following conditions is met? A. The client has completed her six-week postpartum check-up. B. The episiotomy has healed and the lochia has stopped. C. The lochia has turned pink and the vaginal tenderness has subsided. D. The client has had her first menstrual period after childbirth. 35. A woman, 24 hours postpartum, complains of excessive sweating but has no other symptoms. Which of the following actions should the nurse take? A. Measure the woman's temperature. B. Suggest the woman reduce her fluid intake. C. Reassure the woman that this is a normal occurrence. D. Notify the neonate's pediatrician. Situation: Lara, a 30-year-old woman, gave birth to her first child, a healthy baby boy, two days ago. She is experiencing lochia discharges, which are normal vaginal discharges following childbirth. Sarah notices that the color and amount of discharge vary throughout the day, and she has questions about what is considered normal in terms of color, consistency, and duration of lochia. 36. The nurse is assessing the involution progress of a woman who is 3 days postpartum. Which of the following findings would the nurse evaluate as normal? A. Fundus 1 cm above the umbilicus, with lochia that is pink (rosa). B. Fundus 2 cm above the umbilicus, with lochia that is white (alba). C. Fundus 2 cm below the umbilicus, with lochia that is red (rubra). D. Fundus 3 cm below the umbilicus, with lochia that is pink tinged with blood (serosa). 37. During a home visit, the nurse evaluates a client who is 2 weeks postpartum. Which of the following signs or symptoms should the nurse anticipate? A. Profuse sweating (diaphoresis). B. Whitish vaginal discharge (lochia alba). C. Cracked nipples. D. High blood pressure (hypertension). 38. The day after giving birth, a woman's uterus is firm and located 1 cm below the umbilicus. She reports moderate lochia and expresses concern, saying, "All I do is go to the bathroom." What is an appropriate nursing response? A. Catheterize the client as per doctor's orders. B. Monitor the client's next urination. C. Explain to the client that polyuria is normal. D. Assess the specific gravity of the next urination. 39. A breastfeeding client, G10P6408, delivered 10 minutes ago. What is the most critical assessment for the nurse to conduct at this time? A. Pulse. B. Fundus. C. Bladder. D. Breast. 40. The nurse is attending to a Seventh Day Adventist woman who had a cesarean section delivery of a baby boy. Which of the following inquiries should the nurse make regarding the woman’s care? A. “Would you prefer a vegetarian clear liquid diet to be ordered for you?” B. “Do you require any special accommodations for your Sabbath on Sunday?” C. “Would you like assistance in arranging for the baptism with your clergy?” D. “Will a clergy member be performing the circumcision on your baby?” Situation: Emily is currently at 28 weeks of gestation and has been closely monitored due to the higher risks associated with monochorionic pregnancies, she attends regular prenatal appointments to ensure both babies are developing adequately and to address any potential complications promptly. Emily is preparing for the unique challenges and joys of welcoming two babies into her life simultaneously, knowing that careful monitoring and medical management are essential for the health and well-being of her monochorionic twins. 41. A pregnant woman is expecting monochorionic twins. For which of the following complications should this pregnancy be monitored? A. Low amniotic fluid levels B. Placenta covering the cervix C. Disproportion between the fetal head and the mother's pelvis D. Abnormal blood flow between the twins 42. During ultrasound examination, it is observed that a hospitalized woman with monochorionic twins is experiencing twin-to-twin transfusion syndrome. Which of the following should the nurse closely monitor in this client? A. Rapid fundal growth. B. Vaginal bleeding. C. Projectile vomiting. D. Congestive heart failure. 43. A nurse is assessing four clients who are 22 weeks pregnant. The nurse notifies the obstetrician which client may potentially be pregnant with twins. A. The client who states that she feels huge. B. The client with a weight gain of 13 pounds. C. The client whose fundal height measurement is 26 cm. 3 | Page
D. The client whose alpha-fetoprotein level is one-half normal. 44. A pregnant woman at 12 weeks gestation arrives in the emergency department with abdominal cramps and light dark red bleeding. What assessments should the nurse conduct for this client? A. Shortness of breath. B. Enlarging abdominal girth. C. Hyperreflexia and clonus. D. Fetal heart dysrhythmias." 45. Aside from two clients, Nurse Colet assessed other clients and she knew that among the 4 clients, the most high risk for premature rupture of membrane is? A. 30-week gestation with prolapsed mitral valve (PMV). B. 32-week gestation with urinary tract infection (UTI). C. 34-week gestation with gestational diabetes (GDM). D. 36-week gestation with deep vein thrombosis (DVT). Situation: Maria, a 29-year-old woman who is 28 weeks pregnant, attends her routine prenatal appointment. She reports feeling unusually tired, experiencing frequent thirst, and needing to urinate more often than usual. Concerned about her symptoms, her obstetrician orders a glucose tolerance test. 46. A woman with type 1 diabetes is attending a preconception counseling session. The nurse should highlight that during the first trimester, she may experience which of the following? A. A requirement for less insulin than usual. B. A higher likelihood of hyperglycemic episodes. C. Indications of excessive amniotic fluid. D. The necessity for hospitalization for fetal monitoring. 47. A woman’s glucose challenge test (GCT) results show 155 mg/dL one hour after ingesting glucose. Which of the following actions, as directed by the physician, is appropriate? A. Refer the woman for a glucose tolerance test. B. Instruct the woman on self-administration of insulin injections. C. Inform the woman that her results are normal. D. Prescribe oral hypoglycemic medications for the woman. 48. A 25-week-pregnant client, who had eaten a small breakfast, has been notified that her glucose challenge test results were 132 mg/dL 1 hour after ingesting the glucose. Which of the following is appropriate for the nurse to say at this time? A. “Since you ate before the test, the results are invalid and will need to be repeated.” B. “Your test results are higher than normal, so you will need to undergo a more specific test.” C. “Due to the results, you will need to have weekly glycohemoglobin testing.” D. “Your results are within the normal range, so you do not need to worry about gestational diabetes.” 49. In assessing the need for health education in a client, G5P4004, with gestational diabetes, the nurse should ask which of the following questions? A. “How old were you during your first pregnancy?” B. “Do you exercise regularly?” C. “Is your partner diabetic?” D. “Do you work outside the home?” 50. Nurse Staku who is caring for a pregnant diabetic should carefully monitor the client for which of the following? A. Urinary tract infection. B. Multiple gestation. C. Metabolic alkalosis. D. Pathological hypotension. Situation: Sarah is a nursing student studying Sigmund Freud's theory of psychosexual development. She is preparing for an upcoming exam and seeks help from her instructor to understand how to apply Freud's concepts to patient care. Her instructor provides her with a series of situational questions to test her knowledge. 51. A 3-year-old child is admitted to the pediatric unit for a minor surgical procedure. According to Freud's theory of psychosexual development, which stage is this child in? A. Oral Stage B. Anal Stage C. Phallic Stage D. Latency stage 52. A 7-year-old child is struggling with making friends at school. Based on Freud's stages, what is the most appropriate intervention for the nurse to suggest? A. Encouraging oral gratification through snacks B. Providing activities that promote control and autonomy C. Supporting the development of social skills and friendships D. Discussing issues related to sexual identity and curiosity 53. A 2-year-old child is hospitalized and exhibits resistance to toilet training. According to Freud, which psychosexual stage does this resistance correspond to, and how should the nurse address it? A. Offer pacifiers to soothe the child B. Encourage gentle and patient toilet training C. Discuss the child’s fantasies and fears D. Focus on academic and social activities 54. A nurse is caring for an adolescent who is experiencing confusion about sexual identity. According to Freud, which stage is the adolescent in, and what should the nurse focus on? A. Providing comfort and feeding support B. Assisting with toilet training C. Addressing Oedipal conflicts D. Supporting exploration of sexual identity 55. A 5-year-old child exhibits a strong attachment to the opposite-sex parent and rivalry with the same-sex parent. According to Freud, which stage is the child in, and what is this phenomenon called? A. Oral fixation B. Anal retentiveness C. Oedipus/Electra complex D. Social withdrawal Situation: John, a 28-year-old patient, is admitted to the psychiatric unit for treatment of impulsive behavior and difficulty managing stress. The nursing team is working to understand John's behavior through the lens of Freud's concepts of the id, ego, and superego. They are creating a plan to help John develop healthier coping mechanisms and better self-regulation. 56. John often acts on his immediate desires without considering the consequences. Which part of Freud's personality structure is primarily driving John's behavior? A. Id B. Ego C. Superego D. Unconscious 57. During therapy, John begins to recognize that his impulsive actions are creating problems in his relationships. This realization suggests the involvement of which part of Freud's personality structure? A. Id B. Ego C. Superego D. Conscious 58. Maloi often feels guilty after acting on his impulses, even when he achieves what he wants. Which part of Freud's personality structure is responsible for these feelings of guilt? A. Id B. Ego C. Superego D. Preconscious 59. To help Maloi develop better coping mechanisms, the nurse suggests practicing mindfulness and stress management techniques. Which part of Freud's personality structure are these techniques primarily aimed at strengthening? A. Id B. Ego C. Superego D. Subconscious 60. Aiah expresses a desire to adhere to social norms and values, even though it sometimes conflicts with his immediate desires. This internal conflict reflects the interaction between which parts of Freud's personality structure? A. Id and Ego B. Id and Superego 4 | Page