Tiêu đề RECALLS 2 (NP2) - STUDENT COPY ✅

RECALLS EXAMINATION 2 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: Shanley, 28 years old, is 10 weeks pregnant (G2P1) went to the clinic for her prenatal visit. Nurse Ivy assist her during the visit. The following questions apply. 1. Shanley complains that she has been nauseated ever since she became pregnant. What dietary instruction can Nurse Ivy provide her to prevent or relieve nausea and vomiting? (Select all that applies) 1) Eat a few dry crackers or toast before getting out of bed in the morning 2) Eat small but frequent meals 3) Include greasy and highly seasoned food 4) Sip a carbonated beverage A. 1 and 2 B. 1, 2 and 3 C. 1, 2 and 4 D. All of the above 2. Shanley was curious about the benefits of Kegel exercises. Nurse Ivy understands that such measures are indicated for which of the following purpose? A. To strengthen and relax perineal muscles for birth and postpartum B. To achieve stress incontinence C. To loosen vaginal muscles D. To decrease sexual enjoyment 3. Shanley has also been experiencing a burning sensation on her chest. Nurse Ivy knows that this may be a pregnancy-associated discomfort due to which of the following reasons? (Select all that applies) 1. Increase in progesterone levels 2. Increased gastric motility 3. Pressure from the expanding uterus 4. Esophageal reflux A. 1, 2 and 4 B. 1, 3 and 4 C. 1, 2 and 3 D. All of the above 4. During a follow-up visit, Shanley is becoming increasingly conscious of her body image and how she has gained weight and transformed throughout her pregnancy. Nurse Ivy assures her that the bodily changes that occur are part of the process. Which of the following refers to the forward curvature of the lumbar spine seen in pregnant women? A. Kyphosis B. Scoliosis C. Lordosis D. Ketosis 5. The doctor prescribed Shanley with folic acid supplements. Nurse Ivy knows that folate is essential in early pregnancy to prevent which of the following anomalies? A. Cretinism B. Neural tube defects C. Developmental hip dysplasia D. Cryptorchidism Situation: Casey, 38 weeks pregnant, presents to the ED with a ruptured membrane. As Nurse Elaine prepares for her imminent delivery. She is reminded of the importance of amniotic fluid during pregnancy. 6. Nurse Elaine is aware that the approximate amount of amniotic fluid by the end of pregnancy is _____________. A. 500 to 800 mL B. 800 to 1,200 mL C. 1200 to 2000 mL D. More than 2000 mL 7. A major characteristic of amniotic fluid in terms of pH is described by which of the following statements? A. It is slightly acidic with a pH of 5.0 B. It is slightly alkaline with a pH of 3.5 C. It is slightly alkaline with a pH of 7.2 D. It is neutral with a pH of 7.0 8. The following statements are correct when it comes to the characteristics of amniotic fluid EXCEPT? A. It shields the fetus against excessive pressure B. It protects the fetus from changes in temperature C. It promotes umbilical cord prolapse D. It aids in muscular development 9. When assessing vaginal secretions, Nurse Elaine will suspect rupture of membranes when nitrazine paper strip will turn into ______? A. Yellow B. Blue C. Clear D. Green 10. To determine amniotic fluid leakage during a fern test, Nurse Elaine will put Casey in which position during the procedure? A. Dorsal lithotomy B. Sim’s C. Passive leg raise D. Knee-chest Situation: Malou, 18 weeks AOG, is set to undergo amniocentesis. As a delivery room nurse, Reana will be assisting during the procedure. 11. Nurse Reana is aware that amniocentesis done between 15 to 18 weeks of gestation is indicated to diagnose and confirm the following, except? A. genetic abnormalities B. chromosomal disorders C. fetal lung maturity D. metabolic disorders 12. After amniocentesis, Nurse Reana instructs the patient to report the following, except? A. Chills and fever of 38 C B. Bleeding, clot or tissue passage C. Increased fetal movement D. Uterine contractions 13. Ideally, in which position must Nurse Reana put the patient after amniocentesis? A. Supine B. Prone 1 | Page
C. Left side lying D. Right side lying 14. Bladder preparation is necessary prior to the procedure, Nurse Reana understand that amniocentesis performed before the 20th week of gestation requires the bladder to be ____ A. Full B. Empty C. Neurogenic D. No bladder preparation necessary 15. Amniocentesis performed at 36 weeks AOG is indicated to determine the presence of __________. genetic abnormalities chromosomal disorders fetal lung maturity metabolic disorders Situation: Pregnancy comes with risks towards the mother’s well-being and health. Nurse Karylle understands her role in the management of complications associated with pregnancy. 16. Betty, 17 weeks AOG, went to the clinic complaining of mild cramps and moderate vaginal bleeding. Upon physical assessment, her cervix appears to be dilated. Nurse Karylle concludes that she is experiencing ________________. A. Missed abortion B. Threatened abortion C. Incomplete abortion D. Inevitable abortion 17. Delilah calls the health clinic reporting a scant bright red and slight abdominal cramping. Nurse Karylle requested the client to proceed to the clinic. On examination, no cervical dilatation is present. Which type of abortion is suspected in this case? A. Missed abortion B. Threatened abortion C. Incomplete abortion D. Inevitable abortion 18. Which type of miscarriage presents with great danger of maternal hemorrhage due to retained placenta or membranes? A. Missed abortion B. Threatened abortion C. Incomplete abortion D. Habitual abortion 19. Recurrent pregnancy loss of women who have had three spontaneous miscarriages that occured at the same gestational age is considered as which type of abortion? A. Missed abortion B. Threatened abortion C. Incomplete abortion D. Habitual abortion 20. After a complete miscarriage, the nurse should instruct the client to report which of the following as signs of abnormal bleeding? A. 1 soaked sanitary pad for 3 hours B. 3 soaked sanitary pads for an hour C. Minimal passage of small clots D. BP of 100/70 Situation: Nurse Mandy takes on the role of a health educator to spread awareness about sexually transmitted diseases to pregnant women in the community. 21. Nurse Mandy emphasizes that chlamydial infections must be treated during pregnancy to prevent all of the following complications to the mother EXCEPT? A. PID B. PROM C. Preterm labor D. Conjunctivitis 22. Which of these herpesviruses pertains to genital herpes? A. HSV-1 B. HSV-2 C. Cytomegalovirus D. Varicella zoster 23. This stage in HIV among pregnant clients, occurs when the woman converts from having no HIV antibodies in blood serum to having antibodies against HIV. Nurse Mandy emphasizes this stage as the _____________. A. Initial conversion B. Seroconversion C. Asymptomatic D. Symptomatic 24. Tracy, 12 weeks AOG, has been diagnosed with syphilis. Nurse Mandy knows that the causative agent for syphilis is ________. A. Candida albicans B. Borrelia burgdorferi C. Treponema pallidum D. Lactobacillus acidophilus 25. Lea, 10 weeks AOG, was seen at the clinic for cervical warts that began a week ago as small lesions that spread and enlarged into cauliflower-like lesions. Upon perineal examination, it was determined to be caused by human papilloma virus (HPV). Nurse Mandy is aware that these warty growths seen in HPV patients is also referred to as? A. Chancre B. Gumma C. Condyloma latum D. Condyloma acuminatum Situation: Paula, 18 years old, at 32 weeks AOG, came to clinic for consultation. She presents with facial puffiness and swelling in her hands. Her urinalysis reveals traces of protein. She has gained approximately 2 lbs in the past two weeks. The doctor suspects the patient to be preeclampsia as her BP is 148/95. 26. When assessing the blood pressure of a patient who is preeclamptic. Which value is of extreme importance to document? A. Preexisting hypertension B. Systolic BP C. Diastolic BP D. Pre-pregnancy BP 27. Which of the following best describes Paula’s risk for preeclampsia? A. Weight gain B. Presence of edema C. Traces of protein D. Age group 28. In assessing for cerebral edema, which of the following findings suggests presence of moderate ankle clonus? A. 1 involuntary foot movement B. 2 involuntary foot movements C. 3-5 involuntary foot movement D. Over 6 involuntary foot movement 29. None of the following are inappropriate precautions to initiate for hospitalized preeclamptic patients with risk of seizure, EXCEPT? A. Raise side rails B. Minimize sudden noises C. Well-lit and bright lights D. Private room 30. Magnesium sulfate toxicity can be best prevented by administering an initial IV loading dose before a continuous infusion. As a nurse, you know that how much of the drug can lead to respiratory depression? A. 5 to 8 mg B. 8 to 10 mg C. 15 to 20 mg D. More than 20 mg Situation: Nurse Rita works in the maternity unit of a local hospital in Bohol. She is guided by the components that constitute the labor process in her practice. 31. Nurse Rita is aware that the relationship between long axis of the fetal body and mother makes up which component? A. Fetal station B. Fetal attitude C. Fetal lie D. Fetal presentation 32. Nurse Rita is aware that when the presenting part of the fetus has reached the level of the ischial spine, it is considered to be _________? A. Floating B. Engaged C. At outlet D. Dipping 2 | Page
33. All of the following are signs of true labor except? A. Contractions become regular and predictable B. Contractions continue even while ambulating C. Cervical dilatation is noted D. Contractions remain confined in the abdomen and groin 34. Nurse Rita teaches a woman in labor on breathing techniques to alleviate the process of a difficult labor. Which breathing pattern is effective for transition contractions? A. Taking 3 to 4 quick breaths then a forceful exhalation B. Slow deep chest breathing at a rate of 6 to 12 breaths/minute C. Lighter and more rapid breathing up to 40 breaths/min D. Quiet, continuous, very shallow panting at about 60 breaths/min 35. In using the Bishop score, which of the following values indicate the highest favorable status of the cervix and maternal readiness for birth? A. Firm anterior cervix at station 0 with cervical dilation of 6 cm and 70% effacement = 9 B. Firm posterior cervix at station +2 with cervical dilation of 6 cm and 70% effacement = 8 C. Soft anterior cervix at station +1 with cervical dilation of 5 cm and 80% effacement = 13 D. Mid-position cervix with medium consistency at -2 station with cervical dilation of 2 cm and 40% effacement = 5 Situation: Nurse Jenny is assigned to monitor Hannah who has just delivered a healthy newborn. She knows that the postpartum stage is of utmost concern to determine any complications from the labor process. 36. Nurse Jenny is aware that the term used to describe the process whereby reproductive organs return to their non-pregnant state is called _____________. A. Lightening B. Involution C. Lochia D. Effleurage 37. Nurse Jenny will instruct Hannah that her uterus is expected to be no longer palpable at which day in the postpartum period? A. Immediately after birth B. After 4 days postpartum C. After 6 to 8 days postpartum D. After 10 days postpartum 38. After 6 weeks postpartum, the uterus is expected to weigh __________. A. 50 g B. 500 g C. 1000 g D. More than 1 kg 39. Nurse Jenny observes for discharge during the postpartum period. What should expect in the first 3 days after birth, the lochia discharge should _______________. A. The lochia appears colorless and white with large streaks of brownish mucus B. The lochia is pink and brownish with blood and mucus C. The lochia is red in color with blood, mucus and small particles of decidua D. The lochia is absent with presence of an offensive odor 40. Nurse Jenny attends to the needs of the new mother in the delivery suite. As the new mother was about to be discharged from the hospital, she notices the mother has made no attempt to dress her new baby. Which of the following are risk factors for postpartal depression? (Select all that applies). 1. History of depression 2. Lack of effective support 3. Disappointment in the gender of the child 4. Partner did not want a child A. 1 and 2 B. 3 and 4 C. 1, 2 and 3 D. All of the above Situation: Nurse Tess performs newborn assessment on a child who was born 38 weeks and weighs 6 pounds. As an obstetric nurse, she assesses the fetal well-being and status of the newborn. 41. Nurse Tess will assess the APGAR score of a newborn at which appropriate interval? A. 5 and 10 minutes after birth B. 3 and 5 minutes after birth C. 1 and 5 minutes after birth D. 30 minutes after birth 42. Which of the following cues indicate that the retina of the newborn is intact and the lens and cornea are clear from tumor or scarring? A. Presence of a red pupil that occurs while shining a light B. Presence of small, bright red spot on the sclera C. Absence of red reflex D. Pupils are equal, react to light and accommodation 43. While assessing the newborn’s mouth, the presence of thrush is characterized by which of the following? A. Small white cysts on the hard palate B. White patchy areas on the tongue or gums C. Low set ears D. Crossed eyes 44. Nurse Tess will note a good parent-child adaptation to be demonstrated by which of the following attributes, except? A. The mother talks and sings to the baby B. The mother makes no eye contact with the infant C. The mother holds the baby warmly D. The mother is not upset by vomiting and drooling 45. The mother of a newborn girl reports that there were slate-gray patches across the sacrum and buttocks of her newborn. Nurse Tess knows that these are collections of pigment cells that often occur in Asian and African children. She would be correct when she tells the mother that these patches are called? A. Epstein pearls B. Lanugo C. Mongolian spots D. Vernix caseosa Situation: In the newborn unit, Nurse Gabby is knowledgeable of the different newborn reflexes. The following questions apply. 46. A Moro reflex is the single best assessment of neurologic ability in a newborn. Which action for eliciting a Moro reflex in a newborn is best? A. Turn the baby onto her abdomen and see if she can turn her head. B. Make a sharp noise, such as clapping your hands. C. Lift the head while the baby is supine and allow it to fall back 1 inch D. Gently shake the bassinette until the newborn responds by flailing out her arms. 47. Nurse Gabby will interpret a positive Babinski sign when the newborn exhibits which of the following? A. The newborn fans the toes while the sole of foot is being stroked B. The newborn grasps the object in their palm by quickly closing their fingers on it C. The infant turns the head in the direction where the cheek is brushed D. The newborn’s toes grasps when an object is touched at the sole of the foot 48. Parents must not offer solid foods as early as 4 months due to the presence of which newborn reflex that may look as if the newborn is rejecting the food? A. Swallowing reflex B. Extrusion reflex C. Sucking reflex D. Rooting reflex 49. In grading deep tendon reflexes, how would you grade a diminished and hypoactive response? A. 0 B. 1+ C. 2+ D. 4+ 50. Nurse Gabby is aware the Babinski reflex disappears at which appropriate time during the course of the growth of an infant? 3 | Page
A. After 6 months B. After 1 year C. After 3 years D. The reflex persists for a lifetime Situation: Mrs. Janet brought her 3-year old toddler to the ED due to hard stools and constipation. The child is lethargic, pale and has traces of blood in the urine and a temperature of 38.2 C. Upon assessment, the physician suspects the child to have Wilm’s tumor. 51. All of the following are necessary interventions to perform for the child, except? A. Monitor blood pressure at regular intervals B. Palpate the abdomen for any presence of mass C. Measure abdominal girth at least once daily D. Assess for signs of hemorrhage 52. Nurse Vee received orders to reserve 2 units of packed RBC for standby blood transfusion for the child. She knows that the only IV fluid compatible with blood products is ________. A. Plain Lactated Ringers B. 5% Dextrose in Water C. 0.9% Sodium Chloride D. 3% NaCl 53. Surgery was advised by the physician. Mrs. Janet was told that the procedure will be a life-saving measure to eradicate the tumor before metastasis occur. The procedure done for children with Wilm’s tumor is called? A. Adrenalectomy B. Partial nephrectomy C. ESWL D. Whipple’s procedure 54. Chemotherapy was initiated post-surgery. Nurse Vee is aware that which of following chemotherapeutic regimen may cause hemorrhagic cystitis? A. Bleomycin B. Vincristine C. Doxorubicin D. Cyclophosphamide 55. During chemotherapy, Nurse Vee will watch out for bone marrow suppression. The period at which bone marrow suppression is greatest is called as _________. A. Induction B. Remission C. Consolidation D. Nadir Situation: Sheldon is a 2-year-old boy with poor growth recently diagnosed with celiac disease. Her mother reports that he is having a temper tantrum because he wants to eat birthday cake like the other children. His mother gives in and says, “Well, I guess it won’t hurt him to eat a piece this one time.” Nurse Fray is given the task of giving health education to the mother. 56. Nurse Fray is aware that an important nursing consideration in the care of a child with celiac disease is to: A. Refer to a nutritionist for detailed dietary instructions and education. B. Help the child and family understand that diet restrictions are usually only temporary. C. Teach proper hand washing and Standard Precautions to prevent disease transmission. D. Suggest ways to cope more effectively with stress to minimize symptoms. 57. What food choice by the mother of Sheldon indicates a need for further teaching? A. Steamed rice B. Mais con yelo C. Fish fillet D. Oatmeal 58. Children with undiagnosed celiac disease often develop which of the stool characteristics? Ribbon-like stool Tenesmus Steatorrhea Melena 59. Nurse Fray would implement the most appropriate measure to manage Celiac disease by? A. Breastfeeding B. Adherence to a gluten-free diet C. Administration of steroids and immunosuppressants D. Giving water-soluble vitamins, iron and folic acid supplements 60. The classic manifestation of a child with celiac disease often presents with a body that is _________ A. Overweight B. Thin with a distended abdomen C. Thin with a protruding abdomen D. Thick with a sausage-shaped mass in the abdomen Situation: Colin, 5 years of age, was brought by her father to the ED due to sudden onset of cough and DOB with hoarseness of voice. He is drooling with a fever of 39.2 C. Upon inspection, his throat appears inflamed and cherry-red. Nurse Myka suspects epiglottitis as she responds quickly to this situation. 61. Which breath sound should Nurse Myka expect in a child with epiglottitis? A. Friction rub B. Crackles C. Wheezing D. Stridor 62. The following interventions are inappropriate to perform for a child suspected with epiglottitis, except? A. Obtain a throat culture B. Elicit gag reflex with a tongue blade during inspection C. Take oral temperature D. Maintain NPO status 63. Nurse Myka notices the child leaning forward, with an open mouth and chin thrusted forward while supporting the body with the hands. She will interpret this as? A. The child is aggravated B. The child attempts to widen the airway C. The child is struggling to breathe D. The child is not in respiratory distress 64. Epiglottitis is most commonly caused by which causative agent? A. Respiratory syncytial virus (RSV) B. Mycoplasma pneumoniae C. Haemophilus influenza D. Epstein-Barr virus 65. Nurse Myka places the child in nasal cannula at 2 LPM. She knows that the rationale behnd the placement of a humidified oxygen includes all of the following, except? A. Prevents trauma to the airway B. Cools the airway C. Decreases swelling D. To conserve oxygen Situation: Mrs. Welsh brought her child to pediatric ER for consult. She reports that her child has had a sore throat for the past 3 weeks already and began to have fever and muscle pain for the past few days. Nurse Quin notes the presence macular rashes in the child’s chest and back which prompted him to suspect Rheumatic Fever. 66. Nurse Quin would list the following as major signs included in the Jones criteria for the diagnosis of rheumatic fever. (Select all that applies). 1. Carditis 2. Erythema marginatum 3. Polyarthritis 4. Sydenham chorea 5. Subcutaneous nodules 6. Arthalgia 7. Fever A. 1, 2, 3, 5, 7 B. 2, 3, 4, 6, 7 C. 1, 2, 3, 4, 5 D. 3, 4, 5, 6, 7 67. Which laboratory finding is indicative that the child has recently been exposed to a streptococcal infection? A. ESR B. CRP 4 | Page