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RECALLS EXAMINATION 6 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: Nurse Ivy is caring for multiple pregnant clients to gain experience and enhance her knowledge regarding prenatal care. 1. Nurse Ivy is assessing a pregnant woman at 20 weeks' gestation who reports swelling in her legs and frequent headaches. Which assessment finding should Nurse Ivy be most concerned about? A. A blood pressure of 130/85 mmHg B. Edema of the lower extremities C. A sudden increase in weight of 2 kg in one week D. A hemoglobin level of 11.5 g/dL 2. Nurse Ivy is educating a pregnant client about the importance of prenatal vitamins. Which statement by the client indicates a correct understanding of the importance of folic acid? A. “Folic acid helps with my digestion.” B. “Folic acid can prevent neural tube defects in the baby.” C. “Folic acid is primarily for boosting my energy levels.” D. “Folic acid is only necessary in the first trimester.” 3. Nurse Ivy is assessing a pregnant woman at 28 weeks' gestation who presents with severe abdominal pain and decreased fetal movement. What should Nurse Ivy’s priority action be? A. Advise the patient to rest and drink more fluids B. Conduct a thorough fetal assessment and notify the healthcare provider C. Suggest over-the-counter pain relief for the abdominal pain D. Recommend a follow-up appointment in one week 4. Nurse Ivy is assessing a pregnant woman who is 36 weeks' gestation. The patient is experiencing a sudden onset of shortness of breath and a non-productive cough. What is the most appropriate action for Nurse Ivy to take? A. Encourage the patient to lie down and rest B. Perform a thorough respiratory assessment and monitor oxygen saturation C. Increase the patient’s fluid intake D. Refer the patient to a dietitian for a low-sodium diet 5. Situation: Nurse Ivy is discussing the risk factors for developing gestational diabetes with a pregnant woman. Which factor is a significant risk for developing gestational diabetes? A. Being underweight before pregnancy B. Being older than 25 years of age C. Having a family history of diabetes D. Having a history of previous uncomplicated pregnancies 6. Nurse Ivy is preparing a teaching session for a group of pregnant women about labor signs. Which sign should Nurse Ivy emphasize as the most indicative of true labor? A. Lightening B. Braxton Hicks contractions C. Rupture of membranes D. Cervical dilation Situation: Nurse Colet is reviewing her knowledge regarding the signs of pregnancy. The following questions are regarding this. 7. Nurse Colet is assessing a pregnant client who reports frequent urination and nausea. Which of these findings is considered a presumptive sign of pregnancy? A. Positive pregnancy test B. Fetal heartbeat detected via Doppler C. Enlargement of the abdomen D. Nausea and vomiting 8. Nurse Colet is evaluating a client who has recently missed her menstrual period and has noticed a darkening of the areola. Which of these is considered a probable sign of pregnancy? A. Amenorrhea B. Hegar’s sign C. Quickening D. Breast tenderness 9. A pregnant client presents with a positive result on a home pregnancy test. What type of sign of pregnancy does this result represent? A. Presumptive sign B. Probable sign C. Positive sign D. Diagnostic sign 10. Nurse Colet is performing a physical examination and notes a softening of the cervix. Which sign of pregnancy does this finding represent? A. Presumptive sign B. Probable sign C. Positive sign D. Diagnostic sign 11. Nurse Colet is teaching a group of pregnant women about signs of pregnancy. Which statement correctly identifies a positive sign of pregnancy? A. Breast tenderness B. Quickening C. Urinary frequency D. Fetal heartbeat detected by a Doppler device 12. Nurse Colet is assessing a pregnant client who reports feeling fetal movement. What type of sign of pregnancy does this represent? A. Presumptive sign B. Probable sign C. Positive sign D. Diagnostic sign 13. Nurse Colet is discussing the changes in skin pigmentation with a pregnant client. The client reports experiencing a dark line running from the pubic area to the umbilicus. What is this sign called? A. Linea nigra B. Chadwick’s sign C. Ballottement D. Goodell’s sign 14. What instructions should a nurse give to a pregnant patient who is about to undergo an amniocentesis? 1 | Page
A. Strict bed rest is required after the procedure. B. Hospitalization is necessary for 24 hours after the procedure. C. An informed consent needs to be signed before the procedure. D. A fever is expected after the procedure because of the trauma to the abdomen. 15. A pregnant patient in her first trimester contacts a healthcare clinic and reports noticing a thin, colorless vaginal discharge. What should the nurse say to the patient? A. “Come to the clinic immediately.” B. “The vaginal discharge may be bothersome, but is a normal occurrence.” C. “Report to the emergency department at the maternity center immediately.” D. “Use tampons if the discharge is bothersome, but be sure to change the tampons every 2 hours.” 16. The healthcare provider orders a contraction stress test, which yields a negative result. How should the nurse document these findings?" A. A normal test result B. An abnormal test result C. A high risk for fetal demise D. The need for a cesarean section 17. A nurse is teaching a pregnant patient how to perform ‘kick counts.’ Which statement from the patient would suggest that additional instruction is needed? A. “I will record the number of movements or kicks.” B. “I need to lie Flat on my back to perform the procedure.” C. “If I count fewer than 10 kicks in a 2-hour period, it could be because my baby is sleeping.” D. “I need to place my hands on the largest part of my abdomen and concentrate on the fetal movements to count the kicks.” 18. The nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The nurse measures the fundal height in centimeters and notes that the fundal height is 30 cm. How would the nurse interpret this Finding? A. The client is measuring large for gestational age. B. The client is measuring small for gestational age. C. The client is measuring normal for gestational age. D. More evidence is needed to determine size for gestational age. 19. A pregnant client comes in for a routine prenatal visit and reports experiencing irregular contractions. After evaluating the situation, the nurse identifies these as Braxton Hicks contractions. Given this assessment, what would be the appropriate nursing action? A. Contact the primary health care provider. B. Instruct the client to maintain bed rest for the remainder of the pregnancy. C. Inform the client that these contractions are common and may occur throughout the pregnancy. D. Call the maternity unit and inform them that the client will be admitted in a preterm labor condition. 20. A client arrives at the clinic for their first prenatal assessment and informs the nurse that the first day of their last normal menstrual period was October 19, 2023. Using Näegele’s rule, what is the expected date of delivery that the nurse should record in the client’s chart? A. July 12, 2024 B. July 26, 2024 C. August 12, 2024 D. August 26, 2024 SITUATION: Nurse Cianne is utilizing her knowledge regarding the proper task delegation and management in the maternal ward. 21. Nurse Cianne is managing a group of patients on the labor and delivery unit. One of her patients is in early labor and has requested a warm bath to help with discomfort. What should Nurse Cianne do? A. Delegate the task of preparing a warm bath to a nursing assistant. B. Personally prepare and monitor the warm bath for the patient. C. Ask the patient to prepare the bath themselves, providing them with instructions. D. Schedule the bath for a later time when she has more time available. 22. Nurse Cianne needs to monitor the client's vital signs. Which action is most appropriate for Nurse Cianne to delegate? A. Monitoring blood pressure and reporting findings to the healthcare provider. B. Documenting blood pressure readings and any abnormal findings in the patient’s chart. C. Measuring and recording blood pressure readings at regular intervals. D. Explaining to the patient the significance of the blood pressure readings. 23. A client is in early labor and has requested pain management options. Nurse Cianne has several tasks to complete. What should she do regarding the pain management assessment? A. Delegate the assessment of pain management options to a nursing assistant. B. Conduct a thorough assessment of pain management options herself. C. Provide a basic explanation of pain management options and then delegate the detailed discussion to a nursing assistant. D. Refer the client to a pain management specialist for further discussion. 24. Nurse Cianne is preparing a teaching session for a pregnant client about the signs of preterm labor. Which task can she delegate to a nursing assistant? A. Assist in preparing educational materials and handouts. B. Explaining the signs of preterm labor and answering the client’s questions. C. Assessing the client’s understanding of preterm labor signs after the teaching session. D. Reviewing the client’s medical history to tailor the teaching session. 25. A client on the postpartum unit is experiencing difficulty with breastfeeding. Nurse Cianne needs to ensure the client receives appropriate support. What should she do? A. Delegate the task of providing breastfeeding support to a nursing assistant. B. Refer the client to a lactation consultant for specialized support. C. Provide the client with general breastfeeding advice and then delegate follow-up to a nursing assistant. D. Document the client’s difficulty with breastfeeding and wait for the next shift to address it. 26. Nurse Cianne is managing several tasks on the labor and delivery unit. A patient requires continuous fetal monitoring. What is the most appropriate action for Nurse Cianne to take? A. Delegate continuous fetal monitoring to a nursing assistant. B. Perform the continuous fetal monitoring herself. C. Instruct the patient to use a portable fetal monitor at home. D. Schedule the fetal monitoring for later when more time is available. 27. A client on the postpartum unit is experiencing postpartum hemorrhage. Nurse Cianne needs to address the situation urgently. Which action should she take? A. Delegate the task of monitoring the client’s bleeding to a nursing assistant B. Conduct a thorough assessment of the client’s condition and implement interventions. C. Provide emotional support to the client while delegating medical tasks to the nursing assistant. D. Wait for the physician to arrive and assess the situation before taking any action. Situation: Nurse Sergio, committed to providing holistic care to his patients, has recently decided to deepen his understanding of psychological theories to better support his patients' mental health. Today, he is focusing on Freud's psychoanalytic theory, a cornerstone of modern psychology that has significant implications for understanding behavior and mental processes. 28. Nurse Sergio is working with a patient who insists on having an immediate surgery despite being informed of the risks. The patient is acting impulsively without consideration of 2 | Page
consequences. This behavior is most indicative of which Freudian concept? A. Id B. Ego C. Superego D. Conscience 29. Nurse Sergio notices that a patient is anxious and indecisive about treatment options due to conflicting thoughts about their health. The patient is trying to balance their desire for immediate relief with the need for a long-term solution. Which Freudian concept is this patient using? A. Id B. Ego C. Superego D. Subconscious 30. Nurse Sergio is evaluating a patient who feels immense guilt about their behavior and is excessively concerned with following hospital rules and ethical standards. This behavior most closely aligns with which Freudian concept? A. Id B. Ego C. Superego D. Subconscious 31. A patient in Nurse Sergio’s care wants to eat a large amount of dessert despite being on a strict diet for health reasons. The patient’s decision is impulsive and driven by immediate pleasure. This scenario best illustrates which part of Freud's model? A. Id B. Ego C. Superego D. Conscience 32. Nurse Sergio is counseling a patient who feels torn between their desire to ignore their treatment plan for instant relief and their understanding of the long-term benefits of following it. The patient is struggling to make a decision that considers both immediate and future outcomes. This is an example of which Freudian concept? A. Id B. Ego C. Superego D. Subconscious 33. During a therapy session, Nurse Sergio observes that a patient feels strong internal pressure to be perfect and is overly critical of themselves for minor mistakes. This behavior is most closely related to which Freudian concept? A. Id B. Ego C. Superego D. Unconscious 34. A patient in Nurse Sergio’s care is having difficulty adhering to their prescribed treatment regimen because they are primarily focused on immediate gratification and avoid long-term goals. This behavior reflects the influence of which Freudian concept? A. Id B. Ego C. Superego D. Conscious Situation: Nurse Eson is likely in a scenario where understanding Erik Erikson’s stages of psychosocial development is pertinent to his practice. Erik Erikson was a developmental psychologist known for his theory on the psychosocial development of human beings. His theory outlines eight key stages that a person goes through from infancy to late adulthood, each characterized by a specific conflict that needs resolution. 35. Nurse Eson is caring for a 6-month-old infant who is learning to trust their caregivers. The infant is showing signs of comfort and security when interacted with. According to Erik Erikson’s stages of development, what stage is this infant in? A. A. Autonomy vs. Shame and Doubt B. Trust vs. Mistrust C. Initiative vs. Guilt D. Industry vs. Inferiority 36. Nurse Eson is working with a 4-year-old child who is actively exploring their environment and trying new things, but also feels guilty when they make mistakes. This behavior is indicative of which Erikson stage? A. Trust vs. Mistrust B. Autonomy vs. Shame and Doubt C. Initiative vs. Guilt D. Industry vs. Inferiority 37. Nurse Eson is caring for a 12-year-old who is struggling with their sense of competence and comparing themselves to peers. They are feeling either industrious or inferior based on their academic and social achievements. This child is in which Erikson stage? A. Trust vs. Mistrust B. Initiative vs. Guilt C. Industry vs. Inferiority D. Autonomy vs. Shame and Doubt 38. Nurse Eson is assisting an adolescent who is struggling with their identity and exploring different roles. This adolescent is experiencing identity confusion. According to Erikson, what stage is this individual in? A. Autonomy vs. Shame and Doubt B. Industry vs. Inferiority C. Identity vs. Role Confusion D. Intimacy vs. Isolation 39. Nurse Eson is working with a young adult who is focused on forming meaningful relationships and is concerned about their ability to connect deeply with others. This young adult is in which Erikson stage? A. Trust vs. Mistrust B. Autonomy vs. Shame and Doubt C. Intimacy vs. Isolation D. Generativity vs. Stagnation 40. Nurse Eson is helping a middle-aged adult who is evaluating their contributions to society and feeling either a sense of achievement or stagnation. According to Erikson, which stage is this adult experiencing? A. Industry vs. Inferiority B. Intimacy vs. Isolation C. Generativity vs. Stagnation D. Integrity vs. Despair 41. Nurse Eson is working with an elderly patient who reflects on their life with either a sense of fulfillment and wisdom or regret and dissatisfaction. This patient is in which Erikson stage? A. Generativity vs. Stagnation B. Intimacy vs. Isolation C. Integrity vs. Despair D. Identity vs. Role Confusion Situation: Nurse Jean is reviewing her knowledge about play and development. This involves understanding how different types of play and developmental stages interrelate according to key theories in child development. Consider insights from Jean Piaget and Erik Erikson, as well as the practical application of this knowledge in a clinical setting. 42. Nurse Jena is assessing a 2-year-old child who is playing with toy cars in the hospital playroom. The child is pushing the cars around and talking to them as if they were alive. What developmental stage is this child most likely in according to Jean Piaget’s theory? A. Sensorimotor B. Preoperational C. Concrete Operational D. Formal Operational 43. Nurse Jena is working with a 7-year-old child who is focused on organizing their toys in a specific order and following rules during playtime. According to Piaget, what cognitive development stage is the child in? A. Sensorimotor B. Preoperational C. Concrete Operational D. Formal Operational 44. Nurse Jena is observing a 10-year-old child who is feeling very competitive and wants to win in all their hospital-based activities. Which Erikson stage is the child likely navigating? A. Trust vs. Mistrust B. Autonomy vs. Shame and Doubt C. Initiative vs. Guilt D. Industry vs. Inferiority 3 | Page
45. Nurse Jena notices that a 3-year-old child is playing alone but talking out loud about their actions and making up stories. According to Piaget, what type of play is this child engaged in? A. Parallel Play B. Cooperative Play C. Symbolic Play D. Functional Play 46. Nurse Jena is supporting a 16-year-old patient who is exploring different roles and identities through their interests and relationships. Which Erikson stage is this patient in? A. Trust vs. Mistrust B. Autonomy vs. Shame and Doubt C. Initiative vs. Guilt D. Identity vs. Role Confusion 47. Situation: Nurse Jena is interacting with an elderly patient who frequently reflects on their life and expresses feelings of satisfaction with their accomplishments. According to Erikson, which stage of psychosocial development is this patient likely in? A. Trust vs. Mistrust B. Autonomy vs. Shame and Doubt C. Integrity vs. Despair D. Generativity vs. Stagnation 48. Nurse Jena observes a 5-year-old child engaging in cooperative play with other children, sharing toys, and working together on a simple project. Which stage of Erik Erikson’s psychosocial development does this behavior reflect? A. Trust vs. Mistrust B. Autonomy vs. Shame and Doubt C. Initiative vs. Guilt D. Industry vs. Inferiority 49. Nurse Jean is observing an 18-year-old child in the hospital playroom who is playing alone with stuffed toy. The child is deeply focused and does not interact with other children who are nearby. According to Jean Piaget’s theory of play, what type of play is this child engaging in? A. Parallel Play B. Cooperative Play C. Solitary Play D. Associative Play 50. Nurse Jean is observing a 16-year-old adolescent who is participating in a competitive basketball game. The adolescent is focused on both individual performance and teamwork, and is also reflecting on their strategy and skills to improve their game. Which of Jean Piaget’s developmental stages does this type of play and reflection most closely align with? A. Sensorimotor B. Preoperational C. Concrete Operational D. Formal Operational Situation: Nurse Sonia is working in a maternity hospital and is handling clients who are experiencing abortion. 51. Nurse Sonia is helping a patient who is considering elective abortion for personal reasons. What term describes an abortion performed for reasons other than medical necessity? A. Spontaneous Abortion B. Induced Abortion C. Therapeutic Abortion D. Habitual Abortion 52. Nurse Sonia is evaluating a patient who reports spotting and cramping but has no cervical dilation. The patient is worried about the possibility of losing her pregnancy. What type of abortion is the patient most likely experiencing? A. Threatened Abortion B. Inevitable Abortion C. Incomplete Abortion D. Complete Abortion 53. Nurse Sonia is assessing a patient who is experiencing heavy bleeding and cramping and has expelled some of the products of conception. What type of abortion does this describe? A. Complete Abortion B. Incomplete Abortion C. Inevitable Abortion D. Threatened Abortion 54. A patient has experienced the complete loss of all products of conception and has no further symptoms. What type of abortion has the patient experienced? A. Missed Abortion B. Complete Abortion C. Incomplete Abortion D. Habitual Abortion 55.Situation: Nurse Sonia is working with a patient who has retained fetal tissue in the uterus after fetal death, with no immediate symptoms of bleeding or cramping. What type of abortion does this describe? A. Threatened Abortion B. Incomplete Abortion C. Complete Abortion D. Missed Abortion 56. A patient has had three consecutive abortions and is concerned about possible underlying issues. What type of abortion might be considered if the patient has recurrent pregnancy losses? A. Incomplete Abortion B. Habitual Abortion C. Missed Abortion D. Inevitable Abortion 57. Nurse Sonia is discussing with a patient who is considering terminating her pregnancy for personal reasons. What term describes an abortion performed for reasons other than medical necessity? A. Spontaneous Abortion B. Induced Abortion C. Therapeutic Abortion D. Habitual Abortion 58. A patient presents with spotting, cramping, and evidence that her cervix is beginning to dilate. Nurse Sonia suspects that the pregnancy may end soon. What type of abortion is the patient most likely experiencing? A. Threatened Abortion B. Incomplete Abortion C. Inevitable Abortion D. Missed Abortion 59. During labor, which of the following is NOT a preparation the nurse should make? A. Monitor vital signs frequently. B. Place the client on a cardiac monitor and on an external fetal monitor. C. Maintain bed rest, with the client lying supine with the head and shoulders elevated. D. Administer oxygen as prescribed. 60. Abortion is a pregnancy that ends either spontaneously or therapeutically before how many weeks of gestation? A. 20 weeks gestation B. 25 weeks gestation C. 26 weeks gestation D. 37 weeks gestation Situation: Nurse Bia is working in a maternity hospital and is managing clients who are experiencing or are at risk of preeclampsia, a serious pregnancy complication characterized by high blood pressure and potential damage to organs. 61. Nurse Bia, a home care nurse, is visiting a pregnant client who has been diagnosed with preeclampsia. During the visit, Nurse Bia assesses the client’s condition. Which of the following findings indicates a worsening of preeclampsia and warrants immediate notification to the primary health care provider (PHCP)? A. Urinary output has increased. B. Dependent edema has resolved. C. Blood pressure reading is at the prenatal baseline. D. The client complains of a headache and blurred vision. 62. Nurse Bia is performing an assessment on a pregnant client in the last trimester with a diagnosis of preeclampsia. She reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis? A. Enlargement of the breasts B. Complaints of feeling hot when the room is cool C. Periods of fetal movement followed by quiet periods D. Evidence of bleeding, such as in the gums, petechiae, and purpura NO #63 4 | Page

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