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NURSING PRACTICE 2
Situation 1 - Nurse Minette is an independent Nurse Practitioner following-up

referred clients in their respective homes. Here she handles a case of POSTPARTAL
MOTHER AND FAMILY focusing on HOME CARE.
Nurse Minette needs to schedule a first home visit to OB client Leah, when is a
first home-care visit typically
made?
Within 4 days after discharge
Within 24 hours after discharge
Within 1 hour after discharge
Within 1 week of discharge
CORRECT ANSWER: A
RATIONALE: Recommended Schedule of Post partum Care visits:
1st visit – 1st week post Partum preferably 3-5 days
2nd visit- 6 weeks post partum
SOURCE: DOH: Public Health Nursing in the Philippines. Pp 125
Leah is developing constipation from being on bed rest, what measures would you
suggest she take to help
prevent this?
a. Eat more frequent small meals instead of three large one daily
b. Walk for at least half an hour daily to stimulate peristalsis
c. Drink more milk, increased calcium intake prevents constipation
d. Drink eight full glasses of fluid such as water daily
CORRECT ANSWER: B
RATIONALE: Early ambulation, a good diet with adequate roughage and adequate fluid
intake all aid in preventing the problem of constipation. Options A and D are
possible answers but in the situation, bed rest causes the constipation.
Therefore, in order to prevent this allow the postpartal woman to ambulate.
SOURCE:Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp.
644
If you were Minette, which of the following actions, would alert you that a new
mother is entering a postpartal
at taking-hold phase?
a. She urges the baby to stay awake so that she can breast-feed him in her
b. She tells you she was in a lot of pain all during labor
c. She says that she has not selected a name for the baby as yet.
d. She sleeps as if exhausted from the effort of labor
CORRECT ANSWER: A
RATIONALE: Taking hold phase the second phase of the postpartal period where the
woman begins to initiate action. The mother is independent and show care for her
baby.
OPTION B: Taking in phase- the first phase of the postpartal period experienced
when the woman is usually 2-3 days postpartum, she is dependent to others and does
not show interest in taking care of the baby.
OPTION C: Taking in phase
OPTION D: Taking in Phase
SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp
623
4. At 6-week postpartum visit what should this postpartal mother's fundic height
be?
a. Inverted and palpable at the cervix
b. Six fingerbreadths below the umbilicus
c. No longer palpable on her abdomen
d. One centimeter above the symphysis pubis
CORRECT ANSWER: C
RATIONALE: On the first postpartal day, it will be palpable one fingerbreath
below the umbilicus; on the second day, two fingerbreadths below the umbilicus;
and so on. Because a fingerbreadth is about 1cm, this can be recorded as 1cm below
the umbilicus, 2cm below it and so forth. In the average woman by the ninth or
tenth day, the uterus will have contracted so much that it is withdrawn into the
pelvis and can no longer be detected by abdominal palpation.
SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th
edition, Pp 628
This postpartal mother wants to loose the weight she gained in pregnancy, so she
is reluctant to increase
her caloric intake for breast-feeding. By how much should a lactating mother
increase her caloric intake during the first 6 months after birth?
a. 350 cal/day
b. 500 cal/day
c. 200 cal/day
d. 1,000 cal/day
CORRECT ANSWER: B
RATIONALE: A woman who is breast-feeding needs an additional 500 calories (i.e.,
a 2700-kcal diet) and an additional 500ml of fluid ( this may be from the same
source) each day to encourage the production of high quality breast milk.
SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 641
Situation 2 – Nurse Lisa manages her own Reproductive and Children’s Nursing
Clinic in Sorsogon and necessarily she attends to health conditions of mothers and
children. The following questions pertains to the growing fetus.
Obstetrical client Marichu asks how much longer Nurse Lisa will refer to the baby
inside her as an embryo.
What would be your best explanation?
a. Her baby will be a fetus as soon as the placenta forms
b. From the time of implantation until 5 to 8 weeks, the baby is an embryo
c. After the 20th week of pregnancy, the baby is called a zygote
d. This term is used during the time before fertilization
CORRECT ANSWER: B
RATIONALE: Under fetal development:
Pre embryonic period- the 1st 2 weeks after conception
Embryonic period- beginning of the third week through the 8 weeks after conception
Fetal period- beginning of the 9th week after conception and ending with birth
SOURCE: Saunder’s Comprehensive review for the NCLEX-RN. 3RD Edition.pp.253
Marichu is worried that her baby will be born with a congenital heart disease.
What assessment of a fetus
at birth is important to help detect congenital heart defect?
a. Determining that the color of the umbilical cord is not green
b. Assessing whether the umbilical cord has two arteries and one vein
c. Assessing whether the Wharton’s jelly of the cord has a pH higher than 7.2
d. Measuring the length of the cord to be certain that it is longer than 3 feet
CORRECT ANSWER: B
RATIONALE: A normal cord contains one vein and two arteries. The absence of the
umbilical arteries is associated with congenital heart and kidney anomalies,
because the insult that caused the loss of the vessel may have affected other
mesoderm germ layer structures as well.
SOURCE:Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp. 615-
616
Additionally, Nurse Lisa would gather more information about Marichu’s worry about
what may threaten the
health of her baby. What would Nurse Lisa hope to find?
Has Marichu been overly anxious about something
Has Marichu suffered from any communicable/contagious disease at the time of her
early stage of pregnancy
Has Marichu engage in sexual activity during the fetal development state of her
child
Has Marichu engaged in any detrimental activities during the fetal development
stage (e.g. smoking, drinking, taking drugs, a bad fall, or attempts to terminate
pregnancy.)
CORRECT ANSWER: D
RATIONALE: During the early time of organogenesis (organ formation) the growing
structure is most vulnerable to invasion by teratogens. (any factors that affects
the fertilized ovum, embryo, fetus adversely, such as alcohol). It is important to
teach women how to minimize their exposure to teratogens during these times
OPTION B: A number of infections are not teratogenic to a fetus during pregnancy
but are harmful if they are present at the time of birth.
OPTION C: Sexual intercourse does not affect fetal development.
SOURCE:Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp.
190,290, 94
Marichu is scheduled to have an ultrasound examination. What instruction would you

give her before her
examination?
a. You can have medicine for pain for any contraction caused by the test
b. Drink at least 3 glassess of fluid before the procedure
c. The intravenous fluid infused to dilate your uterus does not hurt the
fetus
d. Void immediately before the procedure to reduce your bladder size
CORRECT ANSWER: B
RATIONALE: Before ultrasound, the mother needs to have a full bladder in order for
the sound waves to reflect best and the uterus to be held stable. In order to
ensure a full bladder, a woman should drink a full glass of water 15 minutes
beginning, 90 minutes before the procedure and should not void before the
procedure.
SOURCE:Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp. 615-
616
Marichu is scheduled to have an amniocentesis to test for fetal maturity. What

instruction would you give
her before this procedure?
a. The x-ray used to reveal your fetus position has no long term effects
b. The intravenous fluid infused to dilate your uterus does not hurt the
fetus
c. No more amniotic fluid form afterward, which is why only a small amount
is removed
d. Void immediately before the procedure to reduce your bladder size.
CORRECT ANSWER: D
RATIONALE: Amniocentesis is the withdrawal of amniotic fluid through the abdominal
wall for analysis at 14th-16th week of pregnancy. In preparation for
amniocentesis, ask the woman to void (to reduce the size of the bladder, thus
preventing in advertent puncture).
OPTION A: X-ray is not used in amniocentesis
OPTION B: Intravenous fluid is not infused to dilate the uterus
SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp. 207
Situation 3 - Nurse Anna is a new BSN graduate and has just passed her Licensure
Examination for Nurses in the Philippines. She has likewise been hired as a new
Community Health Nurse in one of the Rural Health Units in their City, which of
the following conditions may be acceptable TRUTHS applied to Community Health
Nursing Practice.
11. Which of the following is the primary focus of community health nursing
practice?
Cure of illnesses
Prevention of illness
Rehabilitation back to health
Promotion of health
CORRECT ANSWER: D
RATIONALE:The primary focus of community health nursing practice is on health
promotion. The community health nurse by the nature of his/her work has the
opportunity and responsibility for evaluating the health status of people and
groups and relating them to practice.
SOURCE: DOH CHN pp. 17
12. In community health nursing, which of the following is our unit of service as
nurses?
The Community
The Extended Members of every family
The individual members of the Barangay
The Family
CORRECT ANSWER: D
RATIONALE: One of the principles of the Community Health Nursing, the family is
the unit of service.
13. A very important part of the Community Health Nursing Assessment Process
includes;
The application of professional judgment in estimating importance of facts to
family and community
Evaluation structures arid qualifications of health center team
Coordination with other sectors in relation to health concerns
Carrying out nursing procedures as per plan of action
CORRECT ANSWER: A
RATIONALE: The process of assessment in community health nursing includes;
intensive fact finding, the application of professional judgment in estimating the
meaning and importance of these facts to the family and the community, the
availability of nursing resources that can be provided, and the degree of change
which nursing intervention can be expected to effect.
SOURCE:DOH CHN pp. 45
14. In community health nursing it is important to take into account the family
health with an equally important
need to perform ocular inspection of the areas activities which are
powerful elements of:
a. evaluation
b. assessment
c. implementation
d. planning
CORRECT ANSWER: B
RATIONALE: Assessment provides an estimate of degree to which a family, group or
community is achieving the level of health possible for them, identify specific
deficiencies for guidance needed and estimates the possible effects of the nursing
interventions.
15. The initial step in the PLANNING process in order to engage in any nursing
project or parties at the community
level involves:
goal-setting
monitoring
evaluation of data
provision of data
CORRECT ANSWER: A
RATIONALE: The plan for nursing action or care is based on the actual and
potential problems that were
Identified and prioritized. Planning nursing actions include the following steps:
1. Goal setting- a goal is declaration of purpose or intent that gives
essential direction to action.
2. Constructing a Plan of Action: the planning phase of community health
nursing process is
concerned with choosing from among the possible courses of
action, selecting
the appropriate types of nursing intervention, identifying
appropriate and available
resources for care and developing an operational plan
3. Developing an Operational Plan- to develop an operational plan, the
community health nurse
must establish priorities, phase and coordinate activities.
4. Implementation of Planned Care- In community health nursing,
implementation involves various
nursing interventions which have been previously set.
5. Evaluation of Care and Services Provided- evaluation is interwoven
in every nursing activity
and every step of the community health nurses.
SOURCE: DOH CHN Page 46-48
16. Transmission of HIV from an Infected Individual to another person occurs:

Most frequently in nurses with needle sticks
Only if there is a large viral load in the blood
Most commonly as a result of sexual contact
In all infants born to women with HIV infection
CORRECT ANSWER: C
RATIONALE: Human Immunodeficiency Virus
Causative agent: Retrovirus- Human T-cell lymphotrophic virus 3 (HTLV-3)
Mode of transmission:
Sexual contact
Blood transfusion
Contaminated syringes, needles, nipper, razor blades
Direct contact of open wound/mucous membrane with contaminated blood, body fluids,
semen and vaginal discharges.
OPTION D: All neonates born to HIV positive mothers acquire maternal antibody to
HIV infection, but not all acquire the infection.
SOURCE: DOH CHN Page 294; Saunders Comprehensive Review for the NCLEX-RN 3rd
edition Page 346
17. The medical record of a client reveals a condition in which the fetus cannot
pass through the maternal pelvis.
The nurse interprets this as:
Contracted pelvis
Maternal disproportion
Cervical insufficiency
Cephalopelvic disproportion
CORRECT ANSWER: D
RATIONALE: A disproportion between the size of the normal fetal head and the
pelvic diameters. This results in failure to progress in labor.
OPTIONS A,B & C does not exist.
18. The nurse would anticipate a cesarean birth for a client who has which
infection present at the onset of labor?
Herpes simplex virus
Human papilloma virus
Hepatitis
Toxoplasmosia
CORRECT ANSWER: A
RATIONALE: If a woman has a primary infection, herpes can be transmitted across
the placenta to cause congenital infection in the newborn, if a woman has primary
or secondary active lesions in the vagina or on the vulva at the time of birth,
herpes infection can be transmitted to the newborn at birth.If no lesion are
present vaginal birth is preferable.
OPTION B: Human Papilloma Virus= the presence of vulvar lesions appears to have no
effect on the fetus during pregnancy, but if they are present in the time of birth
and obstruct the birth canal a C/S may be necessary.
OPTION C: Hepatitis A not known to be transmitted to the fetus. Hepatitis B&C are
spread by exposure to contaminated blood or blood products.
OPTION D: Toxoplasmosis is transmitted to the mother through a raw meat or
handling of cat litter of infected in the the mother; organism is transmitted to
the fetus across the placenta.
19. After a vaginal examination, the nurse determines that the client's fetus is
in an occiput posterior position.
The nurse would anticipate that the client will have:
a. A precipitous birth
b. Intense back pain
c. Frequent leg cramps
d. Nausea and vomiting
CORRECT ANSWER: B
RATIONALE: A posterior position is suggested by a dysfunctional labor pattern such
as a prolonged active
active phase, arrested descent, or fetal heart sounds heard best at the lateral
sides of the abdomen.
A posterior head does not fit the cervix as snugly as one in an anterior
portion. Because this
increases the risk of umbilical cord prolapse, the position of the fetus is
confirmed by vaginal examination
or by sonogram. Because the arc of rotation is greater, it is usual for the labor
to somewhat prolonged.
Because the fetal head rotates against the sacrum, a woman may experience
pressure and pain in
her lower back due to sacral nerve compression. This sensations may be so intense
that she asks for
medication for relief, not for her contractions but for the intense back pressure
and pain.
SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 600-
601
20. The rationales for using a prostaglandin gel for a client prior to the
induction of labor is to:
a. Soften and efface the cervix
b. Numb cervical1 pain receptors
c. Prevent cervical lacerations
d. Stimulate uterine contractions
CORRECT ANSWER: A
RATIONALE: Prostaglandin such as Misoprostol (cytotec) are more commonly used
method of speeding cervical ripening. Applied to the interior surface of the
cervix by a catheter or suppository.
Situation 4 - Nurse Lorena is a Family Planning and Infertility Nurse Specialist

and currently attends to FAMILY PLANNING CLIENTS AND INFERTILE COUPLES. The
following conditions pertain to meeting the nursing needs of this particular
population group.
21. Dina, 17 years old, asks you how a tubal ligation prevents pregnancy. Which
would be the best answer?
a. Prostaglandins released from the cut fallopian tubes can kill sperm
b. Sperm cannot enter the uterus, because the cervical entrance is blocked
c. Sperm can no longer reach the ova, because the fallopian tubes are blocked
d. The ovary no longer releases ova, as there is no where for them to go
CORRECT ANSWER: C
RATIONALE: Tubal ligation= the fallopian tubes are occluded by cautery, crushing,
clamping or blocking and thereby preventing passage of both sperm and ova.
SOURCE:Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 123
22. The Dators are a couple undergoing testing for infertility. Infertility is
said to exist when:
a. a woman has no uterus
b. a woman has no children
c. a couple has been trying to conceive for 1 year
d. a couple has wanted a child for 6 months
CORRECT ANSWER: C
RATIONALE: Infertility is said to exist when a pregnancy has not occurred after at
least 1 year of engaging in unprotected coitus.
23. Another client names Lilia is diagnosed as having endometriosis. This
condition interferes with the
fertility because:
a. endometrial implants can block the fallopian tubes
b. the uterine cervix becomes inflamed and swollen
c. ovaries stop producing adequate estrogen
d. pressure on the pituitary leads to decreased FSH levels
CORRECT ANSWER: A
RATIONALE: Endometriosis refers to the implantation of uterine endometrium or
nodules, that have spread from the interior of the uterus to locations outside the
uterus. If growths occur in the fallopian tube, tubal obstruction may result or
adhesions forming from these growths may displace fallopian tubes away from the
ovaries preventing the entrance of ova into the tubes.
24. Lilia is scheduled to have a hysterosalpingogram. Which of the following,

instructions would you give
her regarding this procedure?
a. She will not be able to conceive for 3 months after the procedure
b. The sonogram of the uterus will reveal any tumors present
c. Many women experience mild bleeding as an after effect
d. She may feel some cramping when the dye is inserted
CORRECT ANSWER: D
RATIONALE: Hysterosalpingogram= a radiologic examination of the fallopian tubes
using a radiopaque medium, is the most frequently used method of assessing tubal
patency. Because the medium is thick, it distends the uterus and tubes slightly,
causing momentary painful uterine cramping.
25. Lilia's cousin on the other hand, knowing nurse Lorena's specialization asks
what artificial insemination by
donor entails. Which would be your best answer if you were Nurse Lorena?
a. Donor sperm are introduced vaginally into the uterus or cervix
b. Donor sperm are injected intra-abdominally into each ovary
c. Artificial sperm are injected vaginally to test tubal patency
d. The husband's sperm is administered intravenously weekly
CORRECT ANSWER: A
RATIONALE: Artificial Insemination is the installation of sperm into the female
reproductive tract to aid conception. The sperm can be instilled into the cervix
(intracervical insemination) or into the uterus (intrauterine insemination. Donor
sperm (artificial insemination by donor or therapeutic donor insemination) can be
used. These test can be used if the man has an inadequate sperm count or the woman
has a vaginal or cervical factor that interferes with sperm motility.
Situation 5 - There are other important basic knowledge in the performance of our
task as Community Health Nurse in relation to IMMUNIZATION these include:
26. The correct temperature to store vaccines in a refrigerator is:

between -4 deg C and +8 deg C
between 2 deg C and +8 deg C
between -8 deg C and 0 deg C
between -8 deg C and +8 deg C
CORRECT ANSWER: B
RATIONALE: Vaccines are substances very sensitive to various temp. to avoid
spoilage and maintain potency, vaccines need to be stored at correct temperature.
Below are recommended storage temperatures of EPI vaccines.
Types/Form of vaccines Storage Temperature

Most Sensitive to Heat Oral Polio (live attenuated)
Measles (freeze dried) -15C to -25C ( at the freezer)
-15C to -25C ( in the body of the refrigerator

Least sensitive to Heat DPT/Hep B
“D” Toxoid which is a weakened toxin

“P” Killed bacteria
“T” Toxoid which is a weakend toxin
Hep B
BCG ( freeze dried)
Tetanus Toxoid +2C to +8C (in the body of the refrigerator)
+2 C to + 8 C ( in the body of the refrigerator)
+2 C to + 8 C ( in the body of the refrigerator)

SOURCE: Public health Nursing in the Philippines, Page 151
27. Which of the following vaccines is not done by intramuscular (IM) injection?
a.Measles vaccine
b.DPT
c.Hep B vaccines
d.DPT
CORRECT ANSWER: A
RATIONALE: Measles vaccine give subcutaneous at the outer part of the upper arm
OPTION B: DPT= intramuscular given at the upper outer portion of the thigh
OPTION C: Hep B vaccine= intramuscular, given at the upper outer portion of the
thigh
OPTION D: DPT= intramuscular given at the upper outer portion of the thigh
SOURCE: Public health Nursing in the Philippines, Page 152
28. According to the new EPI Routine Schedule of immunization, when is Hepa B
vaccine first given?
a. 6 weeks
b. 9 months
c. 12 months
d. at birth
CORRECT ANSWER: D
RATIONALIZATION: Hepa B vaccine is first given at birth. Six weeks interval from
first dose to second dose and 8 weeks interval from second dose to third dose. An
early start of Hep B reduces the chance of being infected and becoming a carrier
and prevents liver cirrhosis and liver cancer.
SOURCE:PHN pp.149
29. This is the vaccine needed before a child reaches one (1) year in order for
him/her to qualify as a "fully
immunized child".
a. DPT
b. Measles
c. Hepatitis B
d. BCG
CORRECT ANSWER: B
Rationale: Because it is given when the child reaches 9 months of age and the last
vaccine to be administered.
SOURCE: DOH CHN page 111
30. Which of the following dose of tetanus toxoid is given to the mother to
protect her .infant from neonatal
tetanus and likewise provide 10 years protection for the mother?
a. Tetanus toxoid 3
b. Tetanus toxoid 2
c. Tetanus toxoid 1
d. Tetanus toxoid 4
CORRECT ANSWER: D
RATIONALE: Tetanus toxoid vaccination for women is important to prevent tetanus in
both mother and the baby. TT4 gives 10 years protection for the mother.
OPTION A: TT3 gives 5 years protection for the mother
OPTION B: TT2 gives 3 years protection for the mother.
OPTION C: TT1 gives no protection
SOURCE: PHN, Page 150
Situation 6 - Records contain those comprehensive descriptions of patient's health

conditions and needs and at the same serve as evidences of every nurse's
accountability in the care giving process. Nursing records normally differ from
institution to, institution nonetheless they follow similar patterns of .meeting
needs for specifics, types of information. The following pertains to
documentation/records management.
31. This special form used when the patient is admitted to the unit. The nurse
completes the information in this
records particularly his/her basic personal data, current illness, previous
health history, health history of the
family, emotional profile, environmental history as well as physical
assessment together with nursing diagnosis
on admission, what do you call this record?
a. Nursing Kardex
b. Nursing Health History and Assessment Worksheet
c. Medicine and Treatment Record
d. Discharge Summary
CORRECT ANSWER: B
RATIONALE: AKA Admission Nursing Assessment/ Initial data base/Nursing History or
Nursing Assessment. This is completed when the client is admitted to the nursing
unit. This forms can be organized according to body systems, functional abilities,
health problems and risks.
OPTION A: Kardex is a widely used, concise method of organizing and recording
data about a client making information quickly accessible to all health
professionals.
OPTION C: Medicine and treatment record- medication flow sheets usually include
designated areas for the date of the medication order, the expiration date, the
medication name and dose, the frequency of administration and route and the nurses
signature.
OPTION D: Nursing Discharge/ Referral Summary- a discharge note and referral
summary are completed when the client is being discharged and transferred to
another institution or to a home setting where a visit by a community health nurse
is required.
SOURCE: Fundamentals of Nursing 7th edition by Barbara Kozier, Page 339
32. These, are sheets/forms which provide an efficient and time saving way to
record information that must be
obtained repeatedly at regular and/or short intervals of time. This does
not replace the progress notes;
instead this record of information on vital signs, intake and output,
treatment, postoperative care, postpartum
care, and diabetic regimen, etc., this is used whenever specific
measurements or observations are needed
to-be documented repeatedly. What is this?
a. Nursing Kardex
b. Graphic Flow sheets
c. Discharge Summary
d. Medicine and Treatment Record
CORRECT ANSWER: B
RATIONALE: Graphic flow sheet- a flow sheet enables nurses to record nursing data
quickly and concisely and provides an easy-to-read record of the clients condition
over time.
OPTION A: Kardex is a widely used, concise method of organizing and recording data
about a client making information quickly accessible to all health professionals.
OPTION C: Nursing Discharge/ Referral Summary- a discharge note and referral
is required.
OPTION D: Medicine and treatment record- medication flow sheets usually include
signature.
SOURCE:Fundamentals of Nursing 7th edition by Barbara Kozier, Page 339
33. These records show all medications and treatment provided on a repeated basis.
What do you call this record?
a. Nursing Health History and Assessment Worksheet
b. Discharge Summary
c. Nursing Kardex
d. Medicine and Treatment Record
CORRECT ANSWER: D
RATIONALE: Medicine and treatment record- medication flow sheets usually include
signature.
OPTION A: AKA Admission Nursing Assessment/ Initial data base/Nursing History or
OPTION B: Nursing Discharge/ Referral Summary- a discharge note and referral
is required.
OPTION C: Kardex is a widely used, concise method of organizing and recording data
SOURCE:Fundamentals of Nursing 7th edition by Barbara Kozier, Page 339
34. This flip-over card is usually kept in a portable file at the Nurses Station.
It has 2-parts: the activity and
treatment section and a nursing care plan section. This carries information
about basic demographic data,
primary medical diagnosis, current orders of the physician to be carried
out by the nurse, written nursing
care plan, nursing orders, scheduled tests and procedures, safety
precautions in-patient care and factors
related to daily living activities/ this record is used in the charge-of-
shift reports or during the beside rounds
or walking rounds. What record is this?
a. Discharge Summary
b. Medicine and Treatment Record
c. Nursing Health History and Assessment Worksheet
d. Nursing Kardex
CORRECT ANSWER: D
RATIONALE: Kardex is a widely used, concise method of organizing and recording
data about a client making information quickly accessible to all health
professionals.
OPTION A: Nursing Discharge/ Referral Summary- a discharge note and referral
is required.
OPTION B: Medicine and treatment record- medication flow sheets usually include
signature.
OPTION C: AKA Admission Nursing Assessment/ Initial data base/Nursing History or
35. Most nurses regard this as conventional recording of the date, time and mode
by which the patient leaves
a healthcare unit but this record includes importantly, directs of planning
for discharge that starts soon
after the" person is admitted to a healthcare institution, it is accepted
that collaboration or multidisciplinary
involvement (of all members of the health team) in discharge results in
comprehensive care, what do
you call this?
Discharge Summary
Nursing Kardex
Medicine and Treatment Record
Nursing Health History and Assessment Worksheet
CORRECT ANSWER: A
RATIONALE: Nursing Discharge/ Referral Summary- a discharge note and referral
is required.
OPTION B: Kardex is a widely used, concise method of organizing and recording data
OPTION C: Medicine and treatment record- medication flow sheets usually include
signature.
OPTION D: AKA Admission Nursing Assessment/ Initial data base/Nursing History or
Situation 7 - Health instructions are essentially given to pregnant mothers.
36. A public health nurse would instruct a pregnant woman to notify the
physician immediately if which of the
following symptoms occur during pregnancy?
a. Presence of dark color in the neck
b. Increased vaginal discharge
c. Swelling of the face
d. Breast tenderness
CORRECT ANSWER: C
RATIONALE: Swelling of the face is a manifestation of mild preeclampsia. Edema in
mild preeclampsia begins to accumulate in the upper part of the body, rather than
just the typical ankle edema of pregnancy.
OPTION A: Presence of a dark color in the neck is caused by increase in
pigmentation, that is caused by melanocyte stimulating hormone which secreted by
the pituitary gland.
OPTION B: Due to increase in the activity of the epithelial cells results in white
vaginal discharge throughout pregnancy
OPTION D: Breast tenderness is due to increase stimulation of breast tissue by
the high estrogen level in the body.
SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp
427,228,229
A woman who is 9 weeks pregnant comes to the health center with moderate bright
red vaginal bleeding. On physical examination, the physician finds the client’s
cervix 2 cm dilated. Which term best describes the client’s condition?
Missed abortion
Incomplete abortion
Inevitable abortion
Threatened abortion
CORRECT ANSWER: C
RATIONALE: Occurs if uterine contractions and cervical dilatation occurs.
OPTION A: The fetus dies in utero but is not expelled
OPTION B: part of the conceptus (usually the fetus) is expelled, but membrane or
placenta in retained in the uterus.
OPTION D: is manifested by vaginal bleeding, initially beginning as scant bleeding
and usually bright red.
There may be slight cramping, but no cervical dilatation is present in vaginal
exam.
In a big government hospital, Nurse Pura is taking care of a woman with a

diagnosis of abruptio placenta.
What complication of this condition is of most concern to Nurse Pura?
a. Urinary tract infection
b. Pulmonary embolism
c. Hypocalcemia
d. Disseminated intravascular coagulation
CORRECT ANSWER: D
RATIONALE: Abruptio placenta occur when the placenta appears to have been
implanted correctly. Suddenly, however, it begins to separate and bleeding
results. Conditions such as abruption placenta causes DIC.
Disseminated intravascular coagulation occurs when there is such extreme bleeding
and so many platelets and fibrin from the general circulation rush to the site
that not enough are left in the rest of the body for further clotting.
Which of the following findings on a newly delivered woman’s chart would indicate
she is risk for
developing postpartum hemorrhage?
a. Post-term delivery
b. Epidural anesthesia
c. Grand multiparity
d. Premature rupture of membrane
CORRECT ANSWER: C
RATIONALE: Multiple gestation distends the uterus beyond average capacity causing
uterine atony. Uterine atony or relaxation of the uterus is the most frequent
cause of postpartal hemorrhage.
OPTION B: Epidural anesthesia causes hypotension because of its blocking effect on
the sympathetic nerve fibers in the epidural space.
OPTION D: premature rupture of membrane will cause prolapsed of the cord and
uterine infection.
SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th
edition, Pp 456-657
Mrs. Hacienda Gracia 35 years old postpartum client is at risk of

thrombophlebitis. Which of the following
nursing interventions decreases her chance of developing postpartum
thrombophlebitis?
a. breastfeeding the newborn
b. early ambulation
c. administration of anticoagulant postpartum
d. immobilization and elevation of the lower extremities.
CORRECT ANSWER: B
RATIONALE: Thrombophlebitis is inflammation with the formation of blood clots.
Ambulation and limiting the time a woman remains in obstetric stirrups encourages
circulation in the lower extremities, promotes venous return and decreases the
possibility of clot formation, helping to prevent thrombophlebitis.
OPTION A: will not prevent thrombophlebitis
OPTION C: will increase risk of pospartal hemorrhage
OPTION D: though elevation of lower extremities promotes venous return,
immobilization could increase risk of thrombophlebitis
Situation 8 - Nurse Joanna works as an OB-Gyne Nurse and attends to several HIGH-
RISK PREGNANCIES: Particularly women with preexisting of Newly Acquired illness.
The following conditions apply.
Bernadette is a 22-year old woman. Which condition would make her more prone than
others to developing
a Candida infection during pregnancy?
a. Her husband plays gold 6 days a week
b. She was over 35 when she became pregnant
c. She usually drinks tomato juice for breakfast
d. She has developed gestational diabetes
CORRECT ANSWER: D
RATIONALE: Candidiasis a vaginal infection spread by the fungus, Candida. It
results in a thick vaginal discharge that resembles creamcheese and is extremely
pruritic. The vagina appears red and irritated. Candidiasis occurs more frequently
during pregnancy than normally because of the increased estrogen level present
during pregnancy, which causes the vaginal ph to be less acidic. It also occurs
less frequently in women being treated with an antibiotic for another infection,
in women with gestational diabetes and in women with HIV infection.
Bernadette develops a deep-vein thrombosis following an auto accident and is

prescribed heparin sub-Q.
What should Joanna educate her about in regard to this?
Some infants will be born with allergic symptoms to heparin
Her infant will be born with scattered petechiae on his trunk
Heparin can cause darkened skin in newborns
Heparin does not cross the placenta and so does not affect a fetus
CORRECT ANSWER: D
RATIONALE: Heparin has large molecules that cannot pass the placental blood
barrier. Therefore it will not affect the baby and is allowed for pregnant
mothers.
The cousin of Bernadette with sickle-cell anemia alerted Joanna that she may need
further instruction on
prenatal care. Which statement signifies this fact?
a. I've stopped jogging so I don't risk becoming dehydrated
b. I take an iron pill every day to help grown new red blood cells
c. I am careful to drink at least eight glasses of fluid everyday
d. I understand why folic acid is important for red cell formation
CORRECT ANSWER: B
RATIONALE: The majority of the red blood cells are irregular or sickle-shaped so
cannot carry as much hemoglobin as normally shaped red blood cells. When oxygen
tension becomes reduced, as happens at high altitudes, or blood becomes more
viscid than usual (dehydration), the cells tend to clump because of the irregular
shape. Thus clumping can result in vessel blockage with reduced blood flow of the
organs. The cells then will hemolyze reducing the number available and causing a
severe anemia.
OPTION A: Dehydration can make the blood more viscous causing the cells to clump.
OPTION C: Increasing the fluid volume of the circulatory system to lower viscosity
are important interventions.
OPTION D: Women do need a folic acid supplement to keep the new cells produced
from being megaloblastic
Bernadette routinely takes acetylsalicylic acid (aspirin) for arthritis, why

should she limit or discontinue this
toward the end of pregnancy?
a. Aspirin can lead to deep vein thrombosis following birth
b. Newborns develop a red rash from salicylates toxicity
c. Newborns develop withdrawal headaches from salicylates
d. Salicylates can lead to increased maternal bleeding at childbirth
CORRECT ANSWER: D
RATIONALE: Women with juvenile rheumatoid arthritis frequently take
corticosteroids and non-steroidal anti-inflammatory drug (NSAID) to prevent joint
pain and loss of mobility. Although they should continue
to take this medications during pregnancy to prevent joint damage, large amount of
salicylates may
lead to increase bleeding at birth or prolong pregnancy (salicylates interferes
withy prostaglandin
synthesis, so labor contractions are not initiated). For this reason, a women is
asked to decrease her intake of salicylates approximately 2 weeks before term.
OPTION A: Aspirin will not cause deep vein thrombosis after birth because it has
an anticoagulant effect that inhibits platelet aggregation.
Bernadette received a laceration on her leg from her automotive accident. Why are
lacerations of lower
extremities potentially more serious in pregnant women than others?
a. Lacerations can provoke allergic responses because of gonadothropic hormone
b. Increased bleeding can occur from uterine pressure on leg veins
c. A woman is less able to keep the laceration clean because o f her fatigue
d. Healing is limited during pregnancy, so these will not heal until after birth
CORRECT ANSWER: B
RATIONALE: Laceration (jagged cut) may involve only the skin layer or may
penetrate to deeper subcutaneous tissue or tendons. Lacerations generally bleed
profusely. Halt bleeding by putting pressure on the edges of the lacerations
( this is difficult to achieve in the lower extremities because venous pressure is
greatly increased in pregnancy.
SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 387-
388
Situation 9 - Still in your self-managed Child Health Nursing Clinic, you

encounter these cases pertaining to the CARE OF CHILDREN WITH PULMONARY
INFECTIONS.
Josie brought her 3-rmonths old child to your clinic because of cough and colds.
Which of the following
is your primary action?
a. Give cotrimoxazole tablet or syrup
b. Assess the patient using the chart on management of children with cough
c. Refer to the doctor
d. Teach the mother how to count her child's bearing
CORRECT ANSWER: B
RATIONALE: The first thing to do is to assess the patient using the chart on
management of child with
cough. You determine if this is an initial visit or follow-up visit for this
problem. Then you check for danger
signs, and ask about the main symptoms: does the child have cough or difficulty
breathing?. After assessing
you then classify and identify the treatment.
SOURCE: IMCI Manual page 2
In responding to the care concerns of children with very severe disease, referral
to the hospital is of the
essence especially if the child manifests which of the following?
Wheezing
Stopped bleeding
Fast breathing
Difficulty to awaken
CORRECT ANSWER: D
RATIONALE: Difficulty to awaken is one of the general danger signs and should be
refer URGENTLY to
hospital.
OPTION C: fast breathing is under pneumonia.
SOURCE: IMCI Manual Page 2
Which of the following is the most important responsibility of a nurse in the

prevention of necessary deaths
from pneumonia and other severe diseases?
Giving of antibiotics
Taking of the temperature of the sick child
Provision of Careful Assessment
Weighing of the sick child
CORRECT ANSWER: C
Rationale: A child with danger signs needs URGENT attention; complete the
assessment and any pre-referral treatment so referral is not delayed.
Proper assessment would help in classifying the child .and proper treatment could
be given.
A child of 2 months is considered manifesting fast breathing if:

50 breaths/min
below 50 breaths/min
50 breaths/minute or more
40 breaths/minute or more
CORRECT ANSWER: C
RATIONALE: If the child is 2 months up to 12 months old, fast breathing is 50
breaths/minute or more
OPTION D: 12 months up, 40 breaths/minute or more
All other options are incorrect
50. Which of the following is the principal focus on the CARI program of the
Department of Health?
Enhancement of health team capabilities
Teach mothers how to detect signs and where to refer
Mortality reduction through early detection
Teach other community health workers how to assess patients
CORRECT ANSWER: C
RATIONALE: The primary focus of the CARI Program is mortality reduction through
early detection
and antibiotic treatment of pneumonia cases among children between the ages of 0
to less than 5 years old.
SOURCE: DOH CHN Page 259

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NURSING PRACTICE 2

Situation 1 - Nurse Minette is an independent Nurse Practitioner following-up

Marichu is scheduled to have an ultrasound examination. What instruction would you

Marichu is scheduled to have an amniocentesis to test for fetal maturity. What

16. Transmission of HIV from an Infected Individual to another person occurs:

Situation 4 - Nurse Lorena is a Family Planning and Infertility Nurse Specialist

24. Lilia is scheduled to have a hysterosalpingogram. Which of the following,

26. The correct temperature to store vaccines in a refrigerator is:

Types/Form of vaccines Storage Temperature

Measles (freeze dried) -15C to -25C ( at the freezer)

-15C to -25C ( in the body of the refrigerator

“D” Toxoid which is a weakened toxin

BCG ( freeze dried)

Tetanus Toxoid +2C to +8C (in the body of the refrigerator)

+2 C to + 8 C ( in the body of the refrigerator)

+2 C to + 8 C ( in the body of the refrigerator)

Situation 6 - Records contain those comprehensive descriptions of patient's health

Situation 7 - Health instructions are essentially given to pregnant mothers.

In a big government hospital, Nurse Pura is taking care of a woman with a

Mrs. Hacienda Gracia 35 years old postpartum client is at risk of

Bernadette develops a deep-vein thrombosis following an auto accident and is

Bernadette routinely takes acetylsalicylic acid (aspirin) for arthritis, why

Situation 9 - Still in your self-managed Child Health Nursing Clinic, you

Which of the following is the most important responsibility of a nurse in the

A child of 2 months is considered manifesting fast breathing if:

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