Tiêu đề RECALLS 2 - NP2 - SC ✅

1 | Page RECALLS 2 EXAMINATION NURSING PRACTICE II CARE OF THE HEALTHY/SICK MOTHER & CHILD NOV 2025 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 III” on the box provided Situation 1 – Patient Natalie, 15 years old, G0P1, AOG 39 weeks, has been admitted at 6:30 in the morning for lumbo-sacral pains and strong uterine contractions every 10 minutes. Nurse Gracie was there to admit her. She uses Focus, Data, Action and Response (FDAR) as the form of charting. 1. In any type of charting  or documentation, which of the following should the nurse refer to and use to generate and describe the status of patient Fe? Nursing __________. A. Assessment B. Process  C. Actions D. Diagnosis 2. Which of the following are the purposes of documentation? To ________. I. Ensure the development of organized comprehensive care plan II. Have a clear and accurate record of what was done to the patient. III. Have an evidence of the health care member’s accountability in giving care IV. Detect patients who are clinically deteriorating A. II, III, IV B. I, II, III, IV C. I, II, III D. I, III, IV 3. Which of the following is the CORRECT definition of focus charting? A. It is an electronically form of documentation of nursing care done to a patient by a registered nurse. B. It is a note, written or electronically generated, to provide documentation related to a specific focus. C. It is a nurse-centered way of documentation that describes the patient status and nursing care rendered. D. It is a nurse-centered approach to documentation. 4. In the given situation, which is the FOCUS? A. Patient Natalie as the admitting nurse B. Lumbo-sacral pains and strong uterine contractions C. 15 years old, G0P1, AOG of 36 weeks D. Admission at 6:30 in the morning 5. What is the term used to describe the patient’s data or assessment, the action done based on the assessment and response based on the action made: A. Progress Note B. Flow sheets C. Standard of Care D. Focus Format Situation: This is the first postoperative day for patient Shiela who delivered by caesarean section (CS). Nurse Gemma a newly hired staff was assigned to her. 6. Patient Shiela asks the nurse why she has to get up and walk the day after surgery. Which of the following is the BEST response of the nurse? Walking hastens _________. A. Hastens lactation B. Relieves pain C. Heals wounds D. Fast recovery from anesthesia 7. Which laboratory finding should the nurse assess on the patient 24 hours after caesarian section delivery upon doctor’s request? A. Trace 1+ proteinuria B. Hematocrit 35% C. White blood cell count 20,000/cu.mm D. Hemoglobin 7.0 g/dL 8. Patient Shiela complains of “afterpains”. What should be the nurse IMMEDIATE action? A. Advise her to stop breast-feeding for a day B. Encourage her to drink more water C. Assess vital signs and pain level D. Administer an analgesic STAT 9. Patient Shiela is to be discharge 3 days after CS delivery. Which of the following observations of the nurse would cause the delay of her discharge and would warrant notification to the physician? A. Moderate amount of lochia rubra B. Fundus is firm at umbilicus C. Pulse rate of 61 beats/minute taken in 24 hours D. Five voidings totaling 240 cc in 12 hours 10. On the third postpartum day, Patient Shiela reports that she has voided five times that morning. What should the nurse INITIALLY do? A. Insert a Foley catheter B. Collect the next voiding and measure the urine amount C. Catheterize the client to check for residual urine D. Call the physician Situation: Patient Apple, 19 years old, is in her first trimester of pregnancy. Because it is her first pregnancy, she went for her prenatal check-up with her mother. She asked a lot of questions which she expects the nurse to answer her. 11. The nurse asked for the personal data of the patient which, to some, Patient Apple did not like to answer. And so she asked: “Why do you need to know if I am married?” what should be a good response of the nurse? “I asked your marital status because _________. A. If you do not have a husband, then that can pose a big problem for you.” B. If you are married then your husband will also suffer from discomforts like you.” C. You need your husband to accompany you every prenatal check-up.” D. Your husband is your best support system during your pregnancy.” 12. The patient asked what is the term for signs such as breast * NLE * NCLEX * CGFNS * HAAD * PROMETRICS * DHA * MIDWIFERY * LET * RAD TECH * CRIMINOLOGY * DENTISTRY * PHARMACY *
2 | Page changes, urinary frequency, fatigue, morning sickness and amenorrhea? A. Probable signs B. Presumptive signs C. Possible signs D. Positive signs 13. The patient asked what causes newborn babies with total absence of extremities. The nurse answered that the cause for Amelia is intake of which of the following medications during pregnancy ___________. A. Anti-emetics B. Antibiotics C. analgesics D. anti-bacterials 14. The patient complained that every morning, she becomes nauseated and oftentimes, she would vomit excessively. “What could be the cause of this,” she asked? The nurse’s answer is: “It is due to increase level of ________.”  A. Heart burn B. Estrogen C. heart rate D. Progesterone 15. The nurse advised patient Patient Apple to report to her physician which of the following MOST important sign, if ever she will suffer from it? A. Cough B. Vaginal bleeding C. Headache D. Strong fetal movement 16. What is the FIRST step among the ten steps for successful breastfeeding? A. Have a written breastfeeding policy that is routinely communicated to all staff. B. Inform all pregnant women about the benefits and management of breastfeeding. C. Foster the establishment of breastfeeding support groups. D. Train all health care staff in skills necessary to implement the policy. 17. When practicing rooming-in, how long should the baby stay with the mother? ______ hours. A. 8 B. 24 C. 12 D. 10 18. What is the CORRECT time for which the mother should initiate breastfeeding? It should be _______ hours after birth. A. ½ B. 1 C. 3  D. 2 19. Jubilee learned that newborn infants should ONLY be given, which of the following? A. Fruit juice B. Breastmilk C. water D. cow’s milk 20. Which is the LAST part of the initiative, as recommended by WHO and UNICEF, for the MBFHI external team to do before its final designation as MBFHI Hospital? A. Assess business facilities if they follow the 10 steps for successful breastfeeding. B. Develop a research on the benefits of breastfeeding within the institution. C. Disseminate the benefits of breastfeeding to communities. D. Follow up mothers if they are exclusively breastfeeding. 21. Heather asks what she must do in order to be healthy in case she becomes pregnant. Which among the answers of Nurse Susane should NOT be followed by Heather? A. Get support from husband and family. B. May have a massage from a lay midwife. C. To readily accept her pregnancy. D. Early prenatal check-up 22. Patrick asks what possible contribution he could give for the normal development of the baby. Nurse Susane agreed that his BEST contribution would be the following EXCEPT __________. A. Stroke Heather’s abdomen and talk to baby B. Provide Heather nutritious food and drinks C. Join wife during prenatal check-up D. May smoke once in a while 23. For the normal developmental of the fetus, Nurse Susane taught the couple that Heather should prevent Folic Acid Deficiency anemia by good diet, correct way of cooking vegetables and taking Folic Acid supplements. Which of the following is NOT included among the outcomes of folic acid deficiency to the baby? A. Cleft lip B. Cleft palate C. Neural tube defect D. Fractures of all types 24. Heather asks the nurse what possible diseases should she avoid that would guarantee health for the baby? These are: 1. Rubella 2. Rheumatic fever 3. Anemia 4. Chronic hypertension A. 1, 2, 3 B. 1, 2, 3, 4 C. 1, 2, 4 D. 2, 3, 4 25. Nurse Susane advised the couple that the BEST way to check the condition of the mother and the baby is to have _________. A. Regular well-selected exercise B. Regular prenatal check-up C. Music therapy D. Good food Situation: A hospitalized adolescent Scottie suddenly has a seizure while his family is visiting. Nurse Nisha notes whole body rigidity followed by general jerking movements. Scottie vomits immediately after seizure. 26. Which of the following would be the PRIORITY nursing diagnosis for Scottie? A. Fluid volume deficit related to vomiting. B. Altered family processes related to chronic illness. C. High risk for infection related to vomiting. D. Risk for aspiration related to loss of consciousness. 27. Which of the following would be the LEAST PRIORITY nursing care for a child with seizure disorder? A. Observation and recording all seizures. B. Ensuring safety and protection from injury. C. Teaching the family about anticonvulsant drug therapy: indication, dosage, route and effects. D. Assessing for signs and symptoms of Increased Intracranial Pressure. 28. Scottie will be taking phenytoin (Dilantin) regularly for seizure control. Which of the following will be the MOST important teaching to Scottie’s family? A. Administer acetaminophen to promote sleep. B. Serve a diet that is high in iron C. Maintain good oral hygiene and dental care D. Omit medication if the child is seizure free. 29. After teaching the parents about their child’s unique psychological needs related to a seizures disorder and possible stressors, which of the following concerns voiced by them would indicate the need for additional teaching? The child’s ___________. A. Feeling different from peers B. Cognitive delays C. Poor self-image D. Dependency 30. Which of the following is NOT  a focus for teaching plan for an adolescent with a seizure disorder? A. Obtaining a driver’s license B. Increase risk for infections C. Peer pressure D. Drug and alcohol use Situation: Any pregnancy may pose a risk. A pregnant woman must therefore submit herself for regular pre- natal consultation in any health facility near her place of abode. A nurse can play an important role in making these pregnant women aware of these risks in all stages of pregnancy.
3 | Page 31. What CHIEF ingredient of the prenatal vitamin for pregnancy nutrition that the patient should look for? A. Vitamin B12 B. Potassium C. Vitamin C D. Folic Acid 32. A woman in labor is at risk for abruptio placenta. Which of the following assessments would MOST convince you and the pregnant woman to believe that this has happened? A. Painless vaginal bleeding and downward trend of BP. B. And increased blood pressure and scanty urination. C. Pain at the lower quadrant and increased pulse rate. D. Sharp fundal pain and discomfort between contractions. 33. A woman 2 ½ months pregnant calls you by telephone because she passed out some “berry-like” blood clots and now has continued dark brown vaginal bleeding. Which of the following is the BEST instruction you should give her? A. “Continue normal activity but take your pulse and respiratory rate every 4 hours.” B. “Come to the health facility if uterine contractions start.” C. “Come to the health facility with any vaginal material passed out.” D. “Maintain bedrest and count the number of perineal pads used every hour.” 34. A woman, 33 weeks pregnant, with preterm rupture of membranes had blood work ordered daily. Which laboratory report would be MOST important to read daily? A. Serum creatinine B. Red blood cell count C. Sodium and potassium levels D. White blood cell count 35. An 18 –year –old delivers to an 8 –pound – baby after 10 hours of labor. In the post-partal period, which of the following would be a PRIORITY concern to assess for by the nurse? A. Endometritis B. Thrombophlebitis C. Bleeding D. Amniotic embolus Situation: Head nurse Eva supervises Nurse Hannah who is assigned to take care of a newborn baby boy named Edwin with a cleft palate. 36. The mother asks the head nurse why the pediatrician recommended that closure of the palate should be done before he is 6 months old. She asked Nurse Hannah to answer her. Which of the following is Nurse Hannah’s APPROPRIATE response? A. “After age 2, surgery is very frightening and should be avoided if possible.” B. “The eruption of the 2-year molars often complicates the surgical procedure.” C. “Surgery should be performed before the child starts to use faulty speech patterns.” D. “As he gets older the palate gets wider and more difficult to repair.” 37. The head nurse continued to ask Nurse Hannah, “A cleft lip predispose an infant to infections PRIMARILY because of which of the following reasons?” A. Waste products that accumulate along the defect. B. Inadequate circulation in the defective area. C. Deficient nutrition from ineffective feeding. D. Mouth breathing that dries the oropharyngeal mucous membranes. 38. Which SIGNIFICANT statement of the mother predisposes her son to cleft lip or palate? A. “On my 6 months of pregnancy, I saw a rabbit with the same case of my son.” B. “I am asthmatic and I usually take steroids.” C. “My mother- in- law doesn’t like me, that’s why she cursed me.” D. “I believe my enemy did some forms of witchcraft on me.” 39. For an infant born with a unilateral cleft lip and palate, which of the following type of feeding will be BEST to use? A. Rubber-tipped syringe or medicine dropper. B. Full breast feeding. C. IV fluids on limited number of ounces. D. Cross-cut rubber nipple. 40. Which of the following is the number ONE consideration in the care of an infant after the surgical repair of a cleft lip? A. Preventing the infant from crying B. Feeding the infant with a spoon for 2 days after surgery C. Placing the infant in a semi-sitting position D. Keeping the infant NPO for 1 say after surgery. Situation 10 – Joyce, on her 35 weeks of gestation, is admitted because of hypertension, BP of 185/110, severe headache and blurred vision. She was placed on imposed bedrest without toilet privileges. The physician orders MgSo4. Nikita is the nurse assigned to her. 41. Which of the following would Nurse Nikita anticipate in then patient’s maternal history? A. On and off vaginal spotting B. Esophageal discomfort is experienced after a heavy meal. C. Weight gain of 20lbs in the 1 st and 2 nd Trimester D. Fetus moves very frequently 42. When a patient is on an imposed bedrest, which of the following can help the patient cope? These are the following, EXCEPT __________. A. Let the patient lie on her side to allow more blood to the uterus. B. Increase fluid intake to 8 glasses a day to prevent constipation. C. Discourage participation of family in patient care to prevent further anxiety. D. Use relaxation techniques to help cope with stress such as music and books. 43. MgSo4 injections are painful to the patient. Which of the following is the BEST route for injection to prevent such negative experience for patient Joyce? A. Intravenous injection at the main IV line. B. Intravenous injection given through “piggy back”. C. Intramuscular on each of the deltoid muscle. D. Deep intramuscular using z-track technique on buttocks. 44. The nurse must be alert to MgSo4 toxicity. Which of the following in NOT included? A. Fetal bradycardia B. Urine output of <30 ml per hour C. Respiration of <12 per min D. Increase in maternal pulse rate 45. Which of the following hospital environment will be MOST conducive to Joyce’s condition? A room that is / with ____________. A. Bright and well-ventilated B. 2 or three other patients C. Quiet and non-stimulating D. A call button for watcher’s use. Situation 11 – Mrs. Paula, 20 years old, visited the prenatal clinic with her husband Christian. Nurse Cynthia noted that the fundus is at the level of the umbilicus. Being her first pregnancy, the patient asks the clinic nurse about pregnancy and childbearing. 46. Based from the assessment of the nurse, what would be the estimated age of gestation, in WEEKS,  if then fundus is at the level of the umbilicus? A. 8 B. 10 C. 20 D. 12 47. When is the placenta, which is the source of estrogen and progesterone, fully developed? It is on the __________ weeks of pregnancy? A. 8 B. 20 C. 16 D. 28
4 | Page 48. Mrs. Paula related that she oftentimes feel nauseated in the afternoon. Which of the following should Nurse Cynthia advise her to do? A. Eat sky flakes and follow it up with water B. Drink iced carbonated drinks C. Drink hot chocolate or coffee D. Eat frequent but small amount of foods. 49.Which of the following periods of pregnancy does organogenesis occur? A. Third B. First C. Second D. Fourth 50.What sign of pregnancy is morning sickness characterized by nausea? A. Probable, subjective B. Presumptive, subjective C. Probable, objective D. Presumptive, objective Situation 12 – A mother in her first trimester of pregnancy is asthmatic and has taken steroids. This resulted to her baby with cleft lip and cleft palate. 51. While assessing a newborn with cleft lip, the nurse should be alerted on which of the following that will MOST likely be compromised? A. Locomotion B. Respiratory status C. GI function D. Sucking ability 52. What is the MOST APPROPRIATE response of the nurse to the mother’s question as to when the child will be ready for a cleft palate repair? Cleft palate repair is usually done _______. A. When a large-holed feeding bottle is ineffective for his feeding B. When the child is completely weaned from bottle feeding C. Prior to the development of speech D. After the child has been toilet trained 53. Elbow restraints are the choice during the patient’s operation. When is the right time to introduce the use of these restraints? It should be during the _________ phase. A. Pre-operative B. Rehabilitative C. intra- operative D. post- operative 54. Before bringing the child to the operating room, what condition of the patient needs immediate notification of the surgeon by the nurse that will warrant suspension of surgery? A. Colic B. Atopic dermatitis C. nasopharyngitis D. eye deviation 55. Include in the post-op plan of care is collaboration and referral of the patient with cleft palate to which of the following APPROPRIATE health care provider? A. Speech therapist B. Dentist C. dietetian D. gynecologist Situation 13 – The giving of medication to a pediatric patient is a serious responsibility of a nurse. The need for accuracy in giving medication is greater than with adult patients. Nurse Yuuh has just been assigned to the Pediatric Wards. 56. Dosage, when giving medicine to pediatric patients, varies according to which of the following? Select all that apply 1. Size 2. Surface area 3. Age of child 4. Height A. 3 only B. 1 and 2 C. 1, 2, 3 D. 1, 2, 3, 4 57. Nurse Yuuh is being reviewed by her Headnurse on administering oral medication on pediatric patients. Which of the following statements below is CORRECT? A. The child should be told to place the tablet in the middle of his tongue and to drink water, fruit juice, milk in order to wash down the tablet. B. A child’s reaction to a dose ordered by a physician is not less predictable than adult’s reaction. C. When giving oral medication, the child as young as two years of age CANNOT be taught to swallow drugs. D. The possibility of error is greater in the giving of medication to children than to adults. 58. In children and infants, which part is often used for intramuscular injection to reduce the risk of vascular and peripheral nerve (sciatic) injuries? A. Deltoid muscle B. Gluteus maximus C. Dorsogluteal D. Vastus lateralis 59. Comprehensive surveys of research reports and case study literature about intramuscular injections revealed that administering medication intramuscularly can produce a variety of serious adverse effects. When asked by the Headnurse what possible complications can arise, Nurse Yuuh should include which of the following? 1. Skin and tissue trauma 2. Muscle fibrosis and contracture 3. Nerve palsies and paralysis 4. Infectious processes such as abscesses or gangrene A. 1, 3, and 4 B. 1, 2, 3, 4 C. 2, 3, 4 D. 1, 2, 3 60. Prior to administering the drugs ordered by the Pediatrician, Nurse Yuuh needs to know if she is giving the ordered medication to the right patient. The FIRST step is __________. A. Check patient’s identification bracelet. B. Compare medication to order to identification bracelet and patient’s stated name and birth date. C. Verify patient’s allergies with chart and with patient. D. Ask patient to state their name and birth date. Situation 14 – Nicole, 5 years of age, is admitted to the Pediatric Ward due to severe otalgia, fever and irritability. The mother informed Nurse Olive, who is assigned to Nicole that patient had upper respiratory infection three weeks prior to admission. The admission diagnosis is acute otitis media (AOM). 61. Nurse Olive makes her INITIAL assessment on Nicole. The patient keeps on crying and constantly pulls her right ear. What is her MOST APPROPRIATE action? A. Assess the description and frequency of pain. B. Take Karen’s vital signs. C. Request parent to carry the child. D. Refer to the attending physician. 62.Nurse Olive is preparing to administer ofloxacin eardrop on Nicole per Doctor’s order. She needs to hold the bottle with her hands to warm up the solution to prevent dizziness for _________. A. 10 minutes B. 5 minutes  C. 3-5 minutes D. 1 to 2 minutes 63. After washing her hands and gently cleaning any discharge that can be removed easily from the outer ear, Nurse Olive positions the child. Which of the following steps follows? A. Gently press the tragus of the ear four times in a pumping motion. B. Drop the medicine into the ear canal. C. Gently pull the outer ear D. Keep the up for five minutes 64. Based on her knowledge on otitis media, Nurse Romana recalls that children are predisposed to AOM due to their Eustachian tubes being, which of the following? Select all that apply.