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.
1. Nurse Minette needs to schedule a first home visit to OB client Leah, when is a first home-care visit typically made? a.Within 4 days after discharge b.Within 24 hours after discharge c. Within 1 hour after discharge d.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 2. 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 3. 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
4. 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. 5. 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 6. 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 7. 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? a. Has Marichu been overly anxious about something b. Has Marichu suffered from any communicable/contagious disease at the time of her early stage of pregnancy c. Has Marichu engage in sexual activity during the fetal development state of her child d. 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 8. 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
9. 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? a.Cure of illnesses b.Prevention of illness c. Rehabilitation back to health d.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? a.The Community b.The Extended Members of every family c. The individual members of the Barangay d.The Family CORRECT ANSWER: D RATIONALE: One of the principles of the Community Health Nursing, the family is the unit of service. SOURCE: DOH CHN pp. 19 13. A very important part of the Community Health Nursing Assessment Process includes; a. The application of professional judgment in estimating importance of facts to family and community b. Evaluation structures arid qualifications of health center team c. Coordination with other sectors in relation to health concerns d. 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. SOURCE: DOH CHN pp. 43 15. The initial step in the PLANNING process in order to engage in any nursing project or parties at the community level involves: a.goal-setting b.monitoring c. evaluation of data d.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: a. Most frequently in nurses with needle sticks b.Only if there is a large viral load in the blood c. Most commonly as a result of sexual contact d.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: a.Contracted pelvis b.Maternal disproportion c. Cervical insufficiency d. 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. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 606 18. The nurse would anticipate a cesarean birth for a client who has which infection present at the onset of labor? a.Herpes simplex virus b.Human papilloma virus c. Hepatitis d.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. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 351 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. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 608 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. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 136 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. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 139 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. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 144 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.
SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 148 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: a.between -4 deg C and +8 deg C b.between 2 deg C and +8 deg C c. between -8 deg C and 0 deg C d.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. Most Sensitive to Heat
Least sensitive to Heat
Types/Form of vaccines Oral Polio (live attenuated)
Storage Temperature -15C to -25C ( at the freezer)
Measles (freeze dried)
-15C to -25C ( in the body of the refrigerator +2C to +8C (in the body of the refrigerator)
DPT/Hep B “D” Toxoid which is a weakened toxin “P” Killed bacteria “T” Toxoid which is a weakend toxin Hep B
+2 C to + 8 C ( in the body of the refrigerator)
BCG ( freeze dried)
+2 C to + 8 C ( in the body of the refrigerator)
Tetanus Toxoid 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 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. OPTION D: 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. 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 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 A: 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 B: 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. OPTION C: Kardex is a widely used, concise method of organizing and recording data about a client making information quickly accessible to all health professionals. 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 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. OPTION B: 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 C: 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. SOURCE: Fundamentals of Nursing 7th edition by Barbara Kozier, Page 339 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? a.Discharge Summary b.Nursing Kardex c. Medicine and Treatment Record d.Nursing Health History and Assessment Worksheet CORRECT ANSWER: A RATIONALE: 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. OPTION B: 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: 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. SOURCE: Fundamentals of Nursing 7th edition by Barbara Kozier, Page 339 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
37. 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? a. Missed abortion b. Incomplete abortion c. Inevitable abortion d. 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. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 417 38. 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. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 417 39. 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 40. 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 SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 136 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.
41. 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. 42. 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? a. Some infants will be born with allergic symptoms to heparin b. Her infant will be born with scattered petechiae on his trunk c. Heparin can cause darkened skin in newborns d. 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. 43. 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 SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 136 44. 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 antiinflammatory 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. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 370 45. 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.
46. 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
47. In responding to the care concerns of children with very severe disease, referral to the hospital is of the a. b. c. d.
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
48. Which of the following is the most important responsibility of a nurse in the prevention of necessary deaths from pneumonia and other severe diseases? a. Giving of antibiotics b. Taking of the temperature of the sick child c. Provision of Careful Assessment d. 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. SOURCE: IMCI Manual Page 2
49. A child of 2 months is considered manifesting fast breathing if: a. 50 breaths/min b. below 50 breaths/min c. 50 breaths/minute or more d. 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 SOURCE: IMCI Manual Page 2 50. a. b. c. d.
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
Situation 10 - You are working as a Pediatric Nurse in your own Child Health Nursing Clinic, the following cases pertain to ASSESSMENT AND CARE of THE NEWBORN AT RISK conditions.
50. Theresa, a mother with a 2 year old daughter asks, "at what age can I be able to take the blood pressure of my daughter as a routine procedure since hypertension is common in the family?" Your answer to this is: a. At 2 years you may b. As early as 1 year old c. When she's 3- years old
d. When she's 6 years old? CORRECT ANSWER: C Rationale: Blood pressure should be included in the routine physical assessment of all children older than 3 years of age. Offer a good explanation of the procedure, especially to young children, because wrapping their arm and applying pressure can be frightening if they are not prepared for it. Blood pressure is difficult to measure in infants due to mechanical problem. Doppler ultrasound blood pressure recording is especially effective with infants. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 1120 52. You typically gag children to inspect the back of their throat. When is it important NOT to solicit a gag reflex? a. when a girl has a geographic tongue b. when a boy has a possible inguinal hernia c. when a child has symptoms of epiglottitis d. when children are under 5 years of age CORRECT ANSWER: C RATIONALE: Epiglottitis is the inflammation of the epiglottis. If a child’s gag reflex is stimulated with a tongue blade, the swollen and inflamed epiglottis can be seen to rise in the back of the throat as a cherry-red structure. It can be so edematous, however gagging procedure causes complete obstruction of the glottis and respiratory failure. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 1252 53. Baby John was given a drug at birth to reverse the effects of a narcotic given to his mother in labor. What drug is commonly used for this? a. Naloxone (Narcan) b. Morphine Sulfate c. Sodium Chloride d. Penicillin G CORRECT ANSWER: A RATIONALE: Naloxone is a drug used to counter act the effects of opiod overdose, for example heroin or morphine overdose. Naloxone is especially used to counter act life threatening depression of CNS and respiratory system. OPTION B: Morphine is a highly potent opiate analgesic drug and is the principal active agent in opium and the prototypical opiod. OPTION C: Sodium chloride AKA: commom salt, table salt. Is the salt most responsible for the salinity of the ocean and of the extracellular fluid of many multicellular organisms. OPTION D: Penicillin is a group of B-lactam antibiotics used in the treatment of bacterial infections caused by susceptible, usually gram positive organisms. SOURCE: Wikipedia the free encyclopedia 54. Why are small-for-gestational-age newborns at risks for difficulty maintaining body temperature? a. They do not have as many fat stores as other infant's b. They are more active than usual so throw off covers c. Their skin is more susceptible to conduction of cold d. They are preterm so are born relatively small in size CORRECT ANSWER: A RATIONALE: An infant is small for gestational age if the birth weight is below the 10th percentile on an intrauterine growth curve for that age. Small for gestational age infants are less able to control body temperature than normal newborns because they lack subcutaneous fat. OPTION B: Infant may seem unusually alert and active for that weight. OPTION D: SGA infants may be born preterm (before week 38 gestation) or term ( between week 38 and 34) or post term (past 42 weeks) SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 757-758 55. Baby John develops hyperbilirubinemia, what is a method used to treat hyperbilirubinemia in a newborn? a. Keeping infants in a warm arid dark environment b. Administration of a cardiovascular stimulant c. Gentle exercise to stop muscle breakdown d. Early feeding to speed passage of meconium CORRECT ANSWER: D RATIONALE: Hyperbilirubinemia refers to an excessive level of accumulated bilirubin in the blood and is characterized by jaundice a yellow discoloration of the skin, sclerae and nails.Early initiation of feedings and frequent breast feeding this measures are aimed at Promoting increased intestinal motility, decreasing enterohepatic shunting, and establishing normal bacterial flora in the bowel to effectively enhance the excretion by conjugated bilirubin. OPTION A: Light promotes bilirubin excretion by photo isomerization which alters the structure of bilirubin to a soluble form (luminubin) for easier excretion. SOURCE: Hockenberry, Marilyn J. Wong’s essentials of Pediatric Nursing.7th edition.pp.263-264 Situation 11 - You are the nurse in the Out-Patient-Department and during your shift you encountered multiple children's condition. The following questions apply.
56. You assessed a child with visible severe wasting, he has: a. edema b.LBM c. kwashiorkor d.marasmus CORRECT ANSWER: D RATIONALE: Marasmus results from general malnutrition of both calories and protein. It is characterized by gradual wasting and atrophy of body tissues, esp. of subcutaneous fat. The child appears to be very old with flabby and wrinkled skin. OPTION A: edema is the abnormal accumulation of fluid in interstitial spaces of tissues such as in the peritoneal cavity or joint capsules. OPTION B: LBM means lean body mass OPTION C: Kwashiorkor has been defined as primarily a deficiency of protein with an adequate supply of calories. The word kwashiorkor means the sickness the older child gets when the next baby is born, and aptly describes the syndrome that develops in the first child, usually between 1 and 4 years of age, when weaned from the breast after the second child is born. Kwashiorkor has thin, wasted extremities and a prominent abdomen from edema (ascites). The edema often masks the severe muscular atrophy, making the child appears debilitated than he/she actually is. The skin is scaly and dry and has areas of depigmentation SOURCE:Hockenberry, Marilyn J. Wong’s essentials of Pediatric Nursing.7th edition.pp 373; Mosby’s pocket dictionary. 4th ed. 57. Which of the following conditions is NOT true about contraindication to immunization? a. do not give DPT2 or DPT3 to a child who has convulsions within 3 days of DPT1 b. do not give BCG if the child has known hepatitis . c. do not give OPT to a child who has recurrent convulsion or active neurologic disease d. do not give BCG if the child has known AIDS CORRECT ANSWER: B RATIONALE: BCG can be given in a child with hepatitis. OPTION A: Vaccines containing the whole cell pertussis component should not be given to children with an evolving neurological disease. (uncontrolled epilepsy of progressive encephalopathy) OPTION D: Live vaccines like BCG vaccine must not be given to individuals who are immunosuppressed due to malignant disease, (e.g. child with clinical AIDS), therapy with immunosuppressive agents on radiation. SOURCE: PHN.pp.143 58. a. b. c.
Which of the following statements about immunization is NOT true? A child with diarrhea who is due for OPV should receive the OPV and make extra dose on the next visit There is no contraindication to immunization if the child is well enough to go home There is no contraindication to immunization if the child is well enough to go home and a child should be immunized in the health center before referrals are both correct d. A child should be immunized in the center before referral CORRECT ANSWER: A RATIONALE: False contraindications to immunizations are children with malnutrition, low grade fever, mild respiratory infections and other minor illnesses and diarrhea should not be considered a contraindication to OPV vaccination. Bur there is no nned to make an extra dose on the next visit. SOURCE: PHN pp. 142 59. a. b. c. d.
A child with visible severe wasting or severe palmar pallor may be classified as: moderate malnutrition/anemia severe malnutrition/anemia not very tow weight no anemia anemia/very low weight CORRECT ANSWER: B Rationale: Visible severe wasting , edema of both feet or severe palmar pallor is classified under severe Malnutrition or severe anemia. Treatment includes give Vit. A and refer URGENTLY to hospital. SOURCE: IMCI manual page 6
60. a. b. c. d.
A child who has some palmar pallor can be classified as: moderate anemia/normal weight severe malnutrition/anemia anemia/very low weight not very low eight to anemia CORRECT ANSWER: C RATIONALE: Some palmar pallor and Very low weight for age is classified under Anemia or Very low Weight. SOURCE: IMCI manual page 6
Situation 12 - Nette, a nurse palpates the abdomen of Mrs. Medina, a primigravida. She is unsure of the date of her last menstrual period. Leopold's Maneuver is done. The obstetrician told her that she appears to be 20 weeks pregnant. .
61. a. b. c. d.
Nette explains this because the fundus is: At the level the umbilicus and the fetal heart can be heard with a fetoscope 18 cm, and the baby is just about to move is just over the symphysis, and fetal heart cannot be heard 28 cm, and fetal heart can be heard with a Doppler CORRECT ANSWER: A RATIONALE: Fundal height is measured to evaluate the fetus gestational age. At 20-22 weeks, the fundus is at the level of umbilicus. OPTION B: 18 weeks-fetal movement can be felt by the mother and the fundus can be found below the umbilicus OPTION C: 12 weeks- at the level of the symphysis pubis OPTION D: 28 weeks- the fundus can be felt between the xyphoid process and the umbilicus SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp. 226
62. In doing Leopold's maneuver palpation which among the following is NOT considered a good preparation? a. The woman should lie in a supine position with her knees flexed slightly b. The hands of the nurse should be cold so that abdominal muscles would contract and tighten c. Be certain that your hands are warm (by washing them in warm water first if necessary) d. The woman empties her bladder before palpation CORRECT ANSWER: B RATIONALE: It should be wash hands using warm water. Handwashing prevents the spread of possible infection. Using warm water aids in client’s comfort and prevents tightening of abdominal muscle. OPTION A: Flexing the knees relaxes the abdominal muscles OPTION D: Doing so promotes comfort and allows for more productive palpation because fetal contour will not obscured by a distended bladder. 63. In her pregnancy, she experienced fatigue and drowsiness. This probably occurs because: a. of high blood pressure b. she is expressing pressure c. the fetus utilizes her glucose stores and leaves her with a low blood glucose d. of the rapid growth of the fetus CORRECT ANSWER: D RATIONALE: Fatigue is extremely common in early pregnancy probably due to increased metabolic requirements. OPTION C: The glucose level of the fetus is about 30mg/100 ml lower than the maternal glucose level. To prevent fetal hypoglycemia, with resultant cell destruction on lack of fetal growth, the maternal glucose level is usually at a higher than normal level during pregnancy. Although, the pancreas secretes an increased level of insulin throughout pregnancy, it appears to be not as effective. With insulin that is less effective, fat stores of the woman are utilizedas well as available glucose. This maintains maternal glucose level at a fairly steady level despite long intervals between meals or days of increased activity. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp. 238 64. The nurse assesses the woman at 20 weeks gestation and expects the woman to report: a. Spotting related to fetal implantation b. Symptoms of diabetes as human placental lactogen is released c. Feeling fetal kicks d. Nausea and vomiting related HCG production CORRECT ANSWER: C RATIONALE: The fetus can be seen to move on ultrasonography as early as the 11th week, although the mother usually does not feel this movement (quickening) until almost 20 weeks of gestation. (presumptive sign of pregnancy). SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp.222 65. If Mrs. Medina comes to you for check-up on June 2, her EDC is June 11, what do you expect during assessment? a. Fundic ht 2 fingers below xyphoid process, engaged b. Cervix close, uneffaced, FH-midway between the umbilicus and symphysis pubis c. Cervix open, fundic ht. 2 fingers below xyphoid process, floating. d. Fundic height at least at the level of the xyphoid process, engaged CORRECT ANSWER: A RATIONALE: The fundic height is 2 cm below the xyphoid process. Lightening is a descent of the fetal presenting part into the pelvis, occurs approximately 10-14 days before labor begins. This changes a woman’s abdominal contour because the uterus becomes lower and more anterior. OPTION B: FH midway between umbilicus and symphysis pubis is 16 weeks gestation OPTION D: FH at the level of the xyphoid process indicates 36 weeks gestation. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp. 489, 226 Situation 13 - Please continue responding as a professional nurse in varied health situations through the following questions.
66. Which of the following medications would the nurse expect the physician to order for recurrent convulsive seizures of a 10-year old child brought to your clinic? a. Phenobarbital b. Nifedipine c. Butorphanol d. Diazepam CORRECT ANSWER: A RATIONALE: Phenobarbital- 10-30 mcg/ml is indicated as anticonvulsants and for febrile seizures. It acts as barbiturates, probably depresses CNS and increases seizure threshold. OPTION B: Nifedipine is a Calcium channel Blocker, used for angina, dysrhythmias and hypertension OPTION C: Butorphanol tartrate is an opioid analgesic indicated for moderate to severe pain OPTION D: Diazepam is an anxiolytics, indicated for anxiety SOURCE: Lippincott Williams and Wilkins. Nursing 2006 Drug handbook.26th Edition.pp. 265 67. RhoGAM is given to Rh-negative women to prevent maternal sensitization from occurring. The nurse is aware that in addition to pregnancy, Rh-negative women would also receive this medication after which of the following? a. Unsuccessful artificial insemination procedure b. Blood transfusion after hemorrhage c. Therapeutic or spontaneous abortion d. Head injury from a car accident CORRECT ANSWER: C RATIONALE: Any woman who does not receive RhoGAM injection after an induced abortion, miscarriage, ectopic pregnancy and amniocentesis can have had antibody formation begins. OPTIONS A, B & D does not expose the mother to fetal blood so therefore will not cause antibody formation that could cross the placenta and cause red blood cell destruction (hemolysis) of fetal RBC. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp.437-38 68. Which of the following would the nurse include when describing the pathophysiology of gestational diabetes? a. Glucose levels decrease to accommodate fetal growth b. Hypoinsulinemia develops early in the first trimester c. Pregnancy fosters the development of carbohydrate cravings d. There is progressive resistance to the effects of insulin CORRECT ANSWER: D RATIONALE: It is known that gestational diabetes results from inadequate insulin response to carbohydrate and from excessive resistance to insulin or a combination of both may occur. OPTION A: To prevent fetal hypoglycemia, with resultant cell destruction on lack of fetal growth, the maternal glucose level is usually at a higher than normal level during pregnancy. OPTION B: The pancreas increases production of insulin in response to the higher levels of glucocorticoid produced by the adrenal glands. Insulin is less effective than normal, however because estrogen, progesterone and HPL are all antagonist to insulin. Therefore a woman who is diabeteic and taking insulin before pregnancy will need more insulin during pregnancy. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp. 378 69. When providing prenatal education to a pregnant woman with asthma, which of the following would be important for the nurse to do? a. Demonstrate how to assess her blood glucose b. Teach correct administration of subcutaneous bronchodilators c. Ensure she seeks treatment for any acute exacerbation d. Explain that she should avoid steroids during her pregnancy CORRECT ANSWER: C RATIONALE: Asthma has the potential of reducing the oxygen supply to the fetus if a major attack should occur during pregnancy. OPTION A: Glucose monitoring is not related to asthma; focus on the stream of the question OPTION B: Bronchodilators such as albuterol sulfate, are given orally or as inhalants. OPTION D: Steroids are allowed in patient with asthma during pregnancy. The inhaled corticosteroid beclomethasone are commonly used by women with persistent asthma and are the best choice for pregnant women and those who might become pregnant. SOURCE:Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp. 368 70. Which of the following conditions would cause an insulin-dependent diabetic client the most difficulty during her pregnancy? a. Rh incompatibility b. Placenta previa c. Hyperemesis gravidarum d. Abruptio placenta CORRECT ANSWER: C Rationale: Hyperemesis gravidarum is nausea and vomiting of pregnancy that is prolonged past week 12 Of pregnancy or is so severe that dehydration, ketonuria and significant weight loss occur within the first 12 weeks of pregnancy. Hyperemesis gravidarum is detrimental in patients with type 1 diabetes because in type 1 DM this can lead to DKA in DKA the blood glucose can reach up to 800mg/dl, therefore the tendency of the body is to
secrete the glucose into the urine (glucosuria) together with the ketones (ketonuria) causing polyuria. Polyuria can cause dehydration. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp. 320 Situation 14 - One important tool a community health nurse uses in the conduct of his/her activities is the CHN Bag. Which of the following BEST DESCRIBES the use of this vital facility for our practice? 71. a. b. c. d.
The Community/Public Health Bag is: a requirement for home visits an essential and indispensable equipment of the community health nurse contains basic medications and articles used by the community health nurse a tool used by the Community health nurse is rendering effective nursing procedure during a home visit CORRECT ANSWER: B RATIONALE: Public health bag is an essential and indispensable equipment of the public health nurse which he/she has to carry along when he/she goes out home visiting. It contains basic medications and articles which are necessary for giving care. OPTION C: an incomplete definition of public health bag OPTION D: Rationale of bag technique SOURCE: DOH CHN pp. 54
72. What is the rationale in the use of bag technique during home visit? a. It helps render effective nursing care to clients or other members of the family b. It saves time and effort of the nurse in the performance of nursing procedures c. It should minimize or prevent the spread of infection from individuals to families d. It should not overshadow concerns for the patient CORRECT ANSWER: A RATIONALE: Options B,C and D are all principles of bag technique SOURCE: DOH CHN pp. 54 73. Which among the following is important in the use of the bag technique during home visit? a. Arrangement of the bag's contents must be convenient to the nurse b. The bag should contain all necessary supplies and equipment ready for use c. Be sure to thoroughly clean your bag especially when exposed to communicable disease cases d. Minimize if not totally prevent the spread of infection CORRECT ANSWER: D RATIONALE: The number 1 principle in bag technique is to minimize if not totally prevent the spread of infection from individuals, families, hence, to the community. OPTIONS A, B and C are all special considerations in the use of bag technique. SOURCE: DOH CHN pp.54 74. This is an important procedure of the nurse during home visits? a. protection of the CHN bag b. arrangement of the contents of the CHN bag c. cleaning of the CHN bag d. proper handwashing CORRECT ANSWER: D RATIONALE: Handwashing is done as frequently as the situation calls for, it helps in minimizing or avoiding contamination of the bag and its contents, because the number 1 principle of ag technique is to prevent spread of infection. OPTION B: the arrangement of content of the bag should be the most convenient to the user to facilitate efficienty and avoid confusion but does not help prevent spread of infection. OPTION C: The bag and its contents should be cleaned as often as possible, supplies replaced and ready for use at anytime. OPTION D: The bag and its contents should be well protected from contact with any article in the home of the patients. Consider the bag and its content clean and sterile while any article belonging to the patient as dirty and contaminated. SOURCE: DOH CHN pp. 54-55 75. Which of the following is not found inside the public health bag? a. apron b. test tube holder c. alcohol lamp d. sphygmomanometer and stethoscope CORRECT ANSWER: D RATIONALIZATION: Options A, B and C are contents of public health bag while option D are carried separately. SOURCE: PHN pp. 52
Situation 15 - As a community health nurse, you may realize that the family is faced with a number of health and nursing problems which cannot be taken up all at the same time considering the available resources of both the family and the nurse. The following questions pertain in prioritizing health problems. 76. In identifying and prioritizing health problems of the family in the community setting, the following factors are identified except: a. Nature of the problem b. Cost of resources c. Salience d. Modifiability CORRECT ANSWER: B RATIONALE: Scale for ranking family health problems according to priorities aims to objectivize priority setting. It has 4 criteria: • Nature of the problem presented • Modifiability of the problem • Preventive potential and • Salience Option B is not included in scale for ranking family health problems. SOURCE: CHN by Maglaya pp. 61-63 77. According to the factors affecting priority setting, which of the following situations would be classified as a health threat that needs immediate attention? a.G2P1 mother with history of pre-eclampsia b.School age children below normal weight c. Mothers who have no knowledge on caring for the young d.Community with 100 people suffering from scabies CORRECT ANSWER: A RATIONALE: Health threats are conditions that promote disease or injury and prevent people from realizing their health potentials Health deficit occurs when there is a gap between actual and achievable health status Foreseable crisis includes stressful occurrences such as death or illness of a family member. OPTIONS B and D: Health deficit OPTION C: Foreseable crisis SOURCE: DOH CHN pp.44 78. A health deficit refers to preventable health problems brought about by lack of knowledge to handle situation. Which of the following is not a health deficit? a.Family size beyond family’s resources b.Malnutrition c. Unsanitary waste disposal d.Cases of malaria CORRECT ANSWER: D RATIONALE: refer to # 77 OPTION D is a health threat OPTIONS A, B and C are health deficit SOURCE: DOH CHN pp.44 79. In formulating goals for family health nursing, there are barriers which the nurse has to identify. Which of the following situation is an identified barrier? a.Family accepts the existence of the problem b.Nurse and family develops a working relationship c. Family perceives problem but belittles it. d.Goals set by both family and nurse is attainable CORRECT ANSWER: C RATIONALE: One of the barriers to joint setting between the nurse and the family is the failure of the family on the part to perceive the existence of the problem. In many instances, the problem is seen only by the nurse while the family is perfectly satisfied with the existing situation. SOURCE: CHN by Maglaya pp.71
80. In planning nursing care in the community health setting, the nurse has to consider the different concepts a. b. c. d.
of planning except: Planning is a set and standardized and rigid Planning is dynamic and continuous Planning entails a systematic process Planning is futuristic. CORRECT ANSWER: A RATIONALE: The following summarize the concepts of planning; • Planning is futuristic
• Planning is change-oriented • Planning is a continuous and dynamic process • Planning is flexible • Planning is a systematic process SOURCE: CHN by Maglaya pp.71
Situation 16 - You are actively practicing nurse who just finished your Graduate Studies. You earned the value of Research and would like to utilize the knowledge and skills gained in the application of research to nursing service. The following questions apply to research. 81. Which type of research inquiry investigates the issue of human complexity (e.g. understanding the human expertise) a. Logical position b. Naturalistic inquiry c. Positivism d. Quantitative Research CORRECT ANSWER: B RATIONALE: Naturalistic inquiry is research that focus on how people behave when they are absorbed in genuine life experiences in natural settings. OPTION A: logical positivism= the philosophy underlying the traditional scientific approach OPTION C: positivism is same with logical positivism OPTION D: Quantitative research= the investigation of phenomena that lend themselves to precise measurement and quantifications, after involving a vigorous and controlled design SOURCE: www.uky.edu/cohort/methods 82. Which of the following studies is based on quantitative research? a. A study examining the bereavement process in spouses of clients with terminal cancer b. A study exploring factors influencing weight control behavior c. A study measuring the effects of sleep deprivation on wound healing d. A study examining client's feelings before, during and after a bone marrow aspiration CORRECT ANSWER: C RATIONALE: Quantitative research is the investigation of phenomena that lead themselves to precise measurement and quantifications, often involving a vigorous and controlled design. OPTIONS A, B and D are qualitative research.
SOURCE: http://www.wilderdom.com/research/QualitativeVersusQuantitativeResearch.html 83. Which of the following studies is based on qualitative research? a. A study examining clients reactions to stress after open heart surgery b. A study measuring nutrition and weight, loss/gain in clients with cancer
c. A study examining oxygen levels after endotracheal suctioning d. A study measuring differences in blood pressure before during and after a procedure CORRECT ANSWER: A RATIONALE: refer to # 82 Other options are quantitative research. 84. An 85 year old client in a nursing home tells a nurse, "I signed the papers for that research study because the doctor was so insistent and I want him to continue taking care of me." Which client right is being violated? a. Right of self determination b. Right to privacy and confidentiality c. Right to full disclosure d. Right not to be harmed CORRECT ANSWER: A RATIONALE: The principle of self-determination means that the prospective participants have the right to decide voluntarily whether to participate in a study, without risking any penalty or prejudicial treatment. A person’s right to self-determination includes freedom from coercion. OPTION B: Participants have the right to expect that any data they provide will be kept in strictest confidence. OPTION C: Full disclosure means that the researcher has fully describe the nature of the study, the person’s right to refuse participation, the researcher’s responsibilities and the likely risks and benefits. OPTION D: Researcher’s should strive to minimize all types of harm and discomfort and to achieve in so far as possible a balance between the potential benefits and risk of being aparticipants. SOURCE: Polit, Denise F and Beck, Cheryl Tatano. Nursing research. Principles and Methods. 7th Edition.pp. 143-149 85. "A supposition or system of ideas that is proposed to explain a given phenomenon," best defines: a. a paradigm b. a concept c. a theory d. a conceptual framework CORRECT ANSWER: C RATIONALIZATION: Theory is an abstract generalization that presents a systematic explaination about the relationship among phenomenon. OPTION A: Paradigm is a way of looking at natural phenomena that encompasses a set of philosophical assumptions and that guides one’s approach to inquiry. OPTION B: Concept an abstraction based on observation of behaviors or characteristics, (examples stress, pain) OPTION D: Is a group of related ideas, statements, or concepts. SOURCE:Polit, Denise F and Beck, Cheryl Tatano. Nursing research. Principles and Methods. 7th Edition Kozier & Erb. Fundamentals of Nursing. 7th Edition. Situation 17 - Nurse Michelle works with a Family Nursing Team in Calbayog Province specifically handling a UNICEF Project for Children. The following conditions pertain, to CARE OP THE FAMILIES PRESCHOOLERS. 86. a. b. c. d.
Ronnie asks constant questions. How many does a typical 3-year-old ask in a day's time? 1,200 or more Less than 50 100-200 300-400 CORRECT ANSWER: D RATIONALE: A 3-year-old child has a vocabulary of about 900 words. These are used to ask questions constantly up to 400 a day, mostly how and why questions. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp. 887
87. Ronnie will need to change to a new bed because his baby sister will need Ronnie's old crib, what measure would you suggest that his parents take to help decrease sibling rivalry between Ronnie and his new sister? a. Move him to the new bed before the baby arrives b. Explain that new sisters grow up to become best friends c. Tell him he will have to share with the new baby d. Ask him to get his crib ready for the new baby CORRECT ANSWER: A RATIONALE: Introduction of a new sibling is such a major happening that parents need to take special steps to be certain their preschooler will be prepared. Help parents not to underestimate the significance of a bed to a preschool child. It is security, consistency and “home”. If the preschooler has been sleeping in a crib that is to be used for the baby, it is usually best if he/she is moved to a bed about 3 months in advance of the birth. The parent’s might explain, “It is time to sleep in a new bed now because you’re a big boy.” The fact that he is growing up is better reason for such a move than because a new brother/sister wants the old bed. The latter is a direct route to sibling rivalry and jealousy. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp. 900-901 88. Ronnie's parents want to know how to react to him when he begins to masturbate while watching television, what would you suggest?
a. They refuse to allow him to watch television b. They schedule a health check-up for sex-related disease c. They remind him that some activities are private d. They give him "timeout" when this begins CORRECT ANSWER: C RATIONALE: it is common for preschoolers to engage in masturbation while watching TV or being read to or before they fall asleep at night. The frequency of this may increase under stress at night. If observing a child doing this bother’s parents, suggest they explain that things are done in some places but not in others. Children can relate to this kind of direction without feeling inhibited, just as they accept the fact that they use a bathroom in private or eat only at table. Calling unnecessary attention to the act can increase anxiety and cause increased not decreased, activity. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp. 902 89. How many words does a typical 12-month-oId infant use? a. About 12 words b. Twenty or more words c. About 50 words d. Two, plus "mama" and "dada" CORRECT ANSWER: D RATIONALE: By ten months an infant masters another word such as “bye-bye” or “no”. At 12 months infants can generally say two words besides “mama” and “dada”, they use those two words with meaning. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 136 90. As a nurse, you reviewed infant safety procedures with Bryan's mother. What are two of the most common types of accidents among infants? a. Aspiration and falls b. Falls and auto accidents c. Poisoning and burns d. Drowning and homicide CORRECT ANSWER: A RATIONALE: Injuries are a major cause of death during infancy, esp. children 6 to 12 months old. According to a recent Canadian survey the top leading causes of injury to infants were falls, ingestion injuries and burns. Constant vigilance, awareness and supervision are essential as the child gains increased locomotor and manipulative skills that are coupled with an unstable curiosity about the environment. SOURCE: Wong’s Essentials of Pediatric Nursing 7th edition Page 346 Situation 18 - Among common conditions found in children especially among poor communities are ear infection/ problems. The following questions apply. 91. a. b. c. d.
A child with ear problem should be assessed for the following EXCEPT: is there any fever? ear discharge if discharge is present for how long? ear pain CORRECT ANSWER: A RATIONALE: A child with ear problem should be assessed for? * Is there pain? * Is there ear discharge? If yes for how long? Look , Feel: -Look for the pus draining from the ear -Feel for tender swelling behind the ear SOURCE:IMCI Manual Page 5
92. If the child does not have ear problem, using IMCI, what should you as the nurse do? a. Check for ear discharge b. Check for tender swellings, behind the ear c. Check for ear pain d. Go to the next question, check for malnutrition CORRECT ANSWER: D RATIONALE: A child with no ear infection, no additional treatment is prescribed and advise mother when to return immediately. Then go to the next question and check for malnutrition SOURCE: IMCI Manual Page 5 93. An ear discharge that has been present for more than 14 days can be classified as: a. mastoditis b. chronic ear infection c. acute ear infection d. complicated ear infection
CORRECT ANSWER: B RATIONALE: Pus seen draining the ear and discharge is reported for more than 14 days is considered chronic ear infection. Nursing interventions includes: * dry the ear by wicking *follow-up in 5 days *advise mother when to return immediately. OPTION A: mastoiditis manifestation according to IMCI tender swelling behind the ear OPTION C: Acute era infection, there is ear pain, pus is seen draining from the ear, and discharge is reported for less than 14 days. OPTION D: not found in IMCi SOURCE: IMCI Manual Page 5 94. An ear discharge that has been present for less than 14 days can be classified as: a. chronic ear infection b. mastoditis c. acute ear infection d. complicated ear infection CORRECT ANSWER: A RATIONALE: Manifestation classified as Chronic Ear Infection is pus seen draining from the ear, and discharge reported for less than 14 days. OPTION B: Mastoiditis if there is tender swelling behind the ear OPTION C: if the manifestation is accompanied by Ear Pain then it is classified as Acute ear pain OPTION D: not a classification in IMCI SOURCE: IMCI Manual Page 5 95. If the child has severe classification because of ear problem, what would be the best thing that you as the nurse can do? a. instruct mother when to return immediately b. refer urgently c. give an antibiotic for 5 days d. dry the ear by wicking CORRECT ANSWER: B RATIONALE: Severe classification of ear problem is classified as mastoiditis. Nursing intervention includes: • give 1st dose of an appropriate antibiotics • give 1st dose of paracetamol for pain • refer URGENTLY to hospital SOURCE: IMCI Manual Page Situation 19 - If a child with diarrhea registers one sign in the pink row and one in the yellow; row in the IMCI Chart. 96. We can classify the patient as: a. moderate dehydration b. some dehydration c. no dehydration d. severe dehydration CORRECT ANSWER: D RATIONALE: Any danger sign classify it as severe dehydration. Examples of danger signs are: *abnormally sleepy or difficult to awaken *sunken eyes *not able to drink or drinking poorly *skin pinch goes back slowly SOURCE: IMCI Manual Page 3 97. The child with no dehydration needs home treatment. Which of the following is not included the rules for home treatment in this case: a. continue feeding the child b. give oresol every 4 hours c. know when to return to the health center d. give the child extra fluids CORRECT ANSWER: B RATIONALE: If the child is classified under no dehydration, treatment includes: • give fluids and food to treat diarrhea at home • give zinc supplements • advice mother when to return immediately • follow-up in 5 days if not improving SOURCE: IMCI Manual Page 98. A child who has had diarrhea for 14 days but has no sign of dehydration is classified as: a. severe persistent diarrhea
b. dysentery c. severe dysentery b. dysentery d. persistent diarrhea CORRECT ANSWER: D RATIONALE: A child with no signs of dehydration is classified under persistent diarrhea. Interventions include: • advice the mother on feeding a child who has persistent diarrhea • give vit. A • follow-up in 5 days • advice mother when to return immediately OPTION A: dehydration present OPTION B: signs include blood in the stookl OPTION C; wrong classification SOURCE: IMCI Manual Page 99. If the child has sunken eyes, drinking eagerly, thirsty and skin pinch goes back slowly, the classification would be: a. no dehydration b. moderate dehydration c. some dehydration d. severe dehydration CORRECT ANSWER: C RATIONALE: Classification under some dehydration, signs include:Two of the following signs • restless, irritable • sunken eyes • drinks eagerly, thirsty • skin pinch goes back very slow OPTION A: No dehydration signs include: • not enough signs to classify as some or severe dehydration OPTION B: moderate dehydration- wrong classification OPTION D: Severe dehydration, two of the following signs: • abnormally sleepy or difficult to awaken • sunken eyes • not able to drink or drinking poorly • skin pinch goes back slow SOURCE: IMCI manual 100. Carlo has had diarrhea for 5 days. There is no blood in the stool, he is irritable. His eyes are sunken the nurse offers fluid to Carlo and he drinks eagerly. When the nurse pinched the abdomen, it goes back slowly. How will you classify Carlo's illness? a. severe dehydration b. no dehydration c. some dehydration d. moderate dehydration CORRECT ANSWER: C RATIONALE: The manifestations of the client are of some dehydration. Other manifestation under the classification is restlessness. OPTION A: Two of the following should be manifested in order to be classified as severe dehydration: • Abnormally sleepy or difficult to awaken • Sunken eyes • Skin pinch goes back very slowly OPTION B: if not enough signs to classify as some or severe dehydration. OPTION D: not part of the classification SOURCE: IMCI manual Page 24
