lOMoARcPSD|12297757

NP2 Recalls

Medical Surgical (Xavier University - Ateneo de Cagayan)

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1. Nurse Jeara is evaluating a pregnant patient 3. She is preparing to assess a client in her second
diagnosed with abruptio placentae. Which symptoms trimester of pregnancy. When measuring fundal height,
should she anticipate observing? Select all what should she expect regarding its relationship to
that apply. gestational age?
I. Uterine irritability
II. Uterine tenderness A. It is less than gestational age.
III. Painless vaginal bleeding - PAINFUL B. It corresponds with gestational age.
IV. Abdominal and low back pain C. It is greater than gestational age.
V. Strong and frequent contractions - LOW INTENSITY D. It has no correlation with gestational age.
VI. Nonreassuring fetal heart rate patterns

A. I, II, III,IV
B. I, II, IV, V
C. I, II, IV, VI
D. II, III, IV

2. While caring for a client in the active stage of labor,

she observes a late deceleration on the fetal monitor
strip. What immediate action should she plan?

A. Document the findings.

B. Prepare for immediate birth.
C. Increase the rate of oxytocin infusion.
D. Administer oxygen to the client via face mask.

4. A pregnant client informs her that she noticed

Late decelerations - Utero placental insufficiency
wetness on her peripad and discovered some clear
Variable: cord compression
fluid. Upon inspecting the perineum, Jeara observes
Early: head compression
the umbilical cord. What should the nurse do
immediately?

A. Monitor the fetal heart rate.

B. Notify the primary health care provider.
C. Transfer the client to the delivery room.
D. Place the client in the Trendelenburg position.

5. She is giving advice to a patient in the third

trimester of pregnancy regarding heartburn
management techniques. Which instructions should
she give to the patient?

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A. Sip some hot tea or milk. 9. A client is admitted to the birthing suite in early
B. Make use of sodium-containing antacids. active labor. The priority nursing intervention on
C. Consume fatty meals only once a day in the admission of this client would be:
morning.
A. Auscultating the fetal heart - FETA WELL BEING
D. Rather than eating short, regular meals, eat three B. Taking an obstetric history
big meals a day. - SFF C. Asking the client when she last ate
D. Ascertaining whether the membranes were ruptured

Situation: 10. A postpartum patient was in labor for 30 hours

Nurses Jessa is assigned in high risk maternity ward. and had ruptured membranes for 24 hours. For
Here are some cases which she handles for the which of the following would nurse Jessa be alert?
morning shift.
A. Endometritis
B. Endometriosis
6. She is caring for a client in labor. She determines
C. Salpingitis
that the client is beginning in the 2nd stage of labor
D. Pelvic thrombophlebitis
when which of the following assessments is noted?

A. The client begins to expel clear vaginal fluid WOF:

B. The contractions are regular Hemorrhage w/in 24 hrs
C. The membranes have ruptured >24 hrs: Infection
D. The cervix is dilated completely

End of 2nd Stage: BABY OUT Situation:

Nurse Tommy, a nurse in Barangay Marilag Health
7. Nurse Jessa is caring for a client in labor and is Center, will conduct Health education to the residents
monitoring the fetal heart rate patterns. The nurse of the Barangay on Reproductive Health.
notes the presence of episodic accelerations on the
electronic fetal monitor tracing. Which of the following 11. A prenatal client is suspected of having iron
actions is most appropriate? deficiency anemia. During the assessment, which
finding should the nurse expect to observe as a result
A. Document the findings and tell the mother that of this condition?
the monitor indicates fetal well-being
B. Take the mothers vital signs and tell the mother A. Dehydration
that bed rest is required to conserve oxygen. B. Overhydration
C. Notify the physician or nurse midwife of the C. A high hematocrit level - indirect measurement
findings. D. A low hemoglobin level
D. Reposition the mother and check the monitor for
changes in the fetal tracing 12. A prenatal client has been diagnosed with a vaginal
infection caused by Candida albicans. What should
8. She is caring for a client with abruptio placenta and he expect to observe during the assessment?
is monitoring the client for disseminated intravascular
coagulopathy. Which assessment finding is least likely A. Costovertebral angle pain - UUTI
to be associated with disseminated intravascular B. No observable signs - UUTI
coagulation? (-) C. Pain, itching, and vaginal discharge - White and
CHEESE-LIKE
A. Swelling of the calf in one leg - DVT D. Proteinuria, hematuria, and hypertension -UUTI
thrombophlebitis
B. Prolonged clotting times 13. For a client starting oral medication, he gives
C. Decreased platelet count instructions regarding the use of oral contraceptives.
[Link], oozing from injection sites, and hematuria Which of the client's statements suggests that more
instruction is necessary? (-)

A. "Every day at the same time, I will take one pill."

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B. "I have to take the missed pill as soon as I

Situation:
remember it if I miss it." Nurse Dan is assigned at the postpartum ward. The
C. "After I begin using these, I won't need to use following questions refer to postpartum patients.
any other birth control methods.”
D. “I will take both pills as soon as I remember if I had 16. Nurse Dan is caring for a postpartum client. He
missed two pills, ,and then two tablets the following should suspect endometritis if which of the following is
day.” observed?

A. Breast engorgement
B. Elevated white blood cell count
C. Lochia rubra on the second day postpartum
D. Fever over 38° C (100.4° F) starting 2 days
postpartum

17. He gives instructions to a new mother who is

preparing to breastfeed her newborn. While observing
the first breastfeeding session, he determines that
further teaching is needed if the new mother performs
which technique? (-)

14. A client with a family history of heart disease A. Turns the newborn onto his side, facing the mother
presents to the primary health care provider's office B. Tilts up the nipple or squeezes the areola,
with a request to start oral contraceptive therapy for pushing it into the newborn's mouth
birth control. What important topic should Nurse Tommy C. Draws the newborn further onto the breast when
ask the client about next? the newborn opens his mouth
D. Inserts a clean finger into the side of the newborn's
A. Smoking - vasoconstriction mouth to break the suction before removing the
B. Regular exercise newborn from the breast
C. Low cholesterol diet
D. Alternative methods of contraception 18. A breastfeeding client, ten days postpartum, calls
the postpartum unit, reporting a painful, reddened
15. Nurse Tommy teaches a pregnant client to perform breast and a fever. Considering the client's symptoms,
Kegel exercises. Which statement by the client what guidance should he provide?
indicates an understanding of the purpose
of these types of exercises? A. "Continue breastfeeding from the unaffected breast
only."
A. “The exercises will help reduce backache.” B. "Cease breastfeeding as it's likely you have an
- PELVIC TILT/PELVIC ROCK infection."
B. “The exercises will help prevent ankle edema.” C. "Contact your healthcare provider as
- LEG ELEVATION medication may be necessary."
C. “The exercises will help strengthen the pelvic D. "Continue with breastfeeding as this reaction is
floor.” typical in breastfeeding mothers."
D. “The exercises will help prevent urinary tract
infections.” 19. When a breastfeeding mother mentions
- Increase Oral Intake experiencing nipple soreness, nurse Dan offers
guidance on alleviating the discomfort. Which
statement from the mother demonstrates
comprehension of the instructions? (+)

A. “I should refrain from changing breastfeeding

positions to toughen the nipple.”
B. “I should temporarily halt nursing to give the
nipples time to heal.”

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C. “I should breastfeed less often and replace some 24. A registered nurse is a preceptor for a new nurse
feedings with bottle feeding until the nipples feel and is observing the new nurse organize the client
better.” assignments and prioritize daily tasks. The registered
D. “I should position my baby so her ear, nurse should intervene if the new nurse implements
shoulder, and hip are aligned and her stomach which action? (-)
is against me.” - PROPER POSITION
A. Provides times for staff meals
20. A new breastfeeding mother, suffering from breast B. Gathers the supplies needed for a task
engorgement, receives guidance on managing the C. Combines all tasks for clients in one list
condition. Which statement from the mother indicates to D. Documents task completions at the end of the
nurse Dan that she comprehends the strategies for day
alleviating discomfort from breast engorgement?
25. When the nurse manager encourages staff to
A. "I will breastfeed using just one breast." provide input in the decision making-process, which
B. "I will use cold compresses on my breasts." leadership style is being demonstrated?
C. "I will refrain from wearing a bra while my breasts
A. Autocratic
are engorged."
B. Situational
D. "I will massage my breasts before feeding to
C. Democratic
stimulate milk letdown."
D. Laissez-faire

Situation:
Situation:
It is essential to perform prompt nursing process to
Nurse Lyka, a maternity nurse, firmly believes that
all patients. Nurse Hannah devotes herself in
everyone should receive good RH education.
performing her best in the maternity ward.

26. She is educating a pregnant client about the

21. During an assessment of a mother who recently
physiological impacts and hormonal shifts during
gave birth to a healthy newborn, where should the
pregnancy. What information should she convey
nurse anticipate finding the fundus positioned?
regarding the function of estrogen?

A. On the right side of the abdomen - Distended

A. Estrogen maintains the uterine lining to facilitate
Bladder
implantation. - PROGESTERONE
B. Level with the umbilicus
B. Estrogen boosts glucose metabolism and converts
C. Above the umbilicus - Retained placental F.
glucose into fat. - HPL
D. One finger's breadth above the symphysis pubis
C. Estrogen inhibits the regression of the corpus
luteum, maintaining progesterone production until
22. A new mother received an intramuscular injection of
the placenta forms. - HCG
methylergonovine maleate following delivery. The
D. Estrogen stimulates uterine growth to create a
nurse comprehends that this medication was
conducive environment for the fetus and
administered for what purpose?
primes the breasts for lactation.

A. To decrease uterine contractions.

27. She is preparing to conduct a class on testicular
B. To prevent postpartum hemorrhage.
self-examination (TSE) at a local high school, should
C. To sustain normal blood pressure.
incorporate which guidance for the attendees?
D. To diminish the amount of lochia drainage.
A. Conduct the self-examination every two months. -
23. Methylergonovine maleate is prescribed for a
1x/month
woman who has just delivered a healthy newborn.
B. Perform the self-examination following a cold
Which is the priority assessment to complete before
shower.- WARM
administering the medication?
C. Anticipate slight discomfort during the
self-examination. - NO PAIN
A. Lochia
D. Gently roll the testicle between the thumb and
B. Uterine tone
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28. She is teaching a group of females how to prevent

pelvic inflammatory disease (PID). What instruction 32. Nurse Angel is assessing a postterm infant. Which
should the nurse include? physical characteristic should the nurse expect to
observe?
A. To douche monthly
B. To avoid unprotected intercourse - STI A. Peeling skin - Desquamation
C. To use only ultra-low dose oral contraceptive pills B. Smooth soles without creases - Preterm
D. To consult with a gynecologist regarding the C. Lanugo covering the entire body-Preterm
placement of an intrauterine device (IUD) D. Thick layer of vernix covering the body-Preterm
PID worse complication: INFERTILITY/STERILITY
33. A postterm infant delivered vaginally is showing
and Ectopic Pregnancy
signs of tachypnea, grunting, retractions, and
nasal flaring. Angel interprets these findings as
29. She is providing discharge teaching to a client after indicative of which condition?
a vasectomy. Which statement by the client indicates
the need for further teaching? (-)
A. Hypoglycemia
B. Respiratory distress syndrome
A. “I can use scrotal support if I need to.”
- Preterm; underdeveloped lungs
B. “I don’t need to practice birth control any
C. Meconium aspiration syndrome
longer.” - NEED FOLLOW UP first
D. Transient tachypnea of the newborn
C. “I can resume sexual intercourse whenever I want.”
D. “I can use an ice bag and take an analgesic for pain
34. The nurse is evaluating a 3-day-old preterm
or swelling.”
neonate diagnosed with respiratory distress
syndrome (RDS). Which assessment finding suggests
30. She asks a student to identify risk factors for and
improvement in the neonate's respiratory condition?
methods of preventing prostate cancer. Which
statement by the student indicates the need for further
A. Edema of the hands and feet - low protein (albumin)
teaching? (-)
B. Urine output of 3 mL/kg/hour
C. Presence of a systolic murmur
A. “Smoking increases the risk for this type of cancer.”
D. Respiratory rate ranging from 60 to 70 breaths per
B. “A high-fat diet will assist in preventing this type
minute - N: 30-60
of cancer.”
C. “A history of a sexually transmitted infection is a risk
35. A newborn baby whose mother is Rh negative is
for this disease.”
told to be admitted to the nursery by the nurse. Which
D. “Men more than 50 years old should be monitored
move should the Angel make in preparation for the
with a yearly digital rectal exam.”
infant's arrival?

Situation: A. Determine the blood type of the newborn and

Preterm newborns are considered high risk because direct Coombs results.
of their immaturity to adapt to the extrauterine life. B. Acquire from the blood bank the supplies required
for an exchange transfusion.
31. On assessment of a newborn being admitted to the C. Request the installation of a phototherapy unit by
nursery, Nurse Angel palpates the anterior fontanel calling the maintenance department to be taken to
and notes that it feels soft. She determines that this the nursery.
finding indicates which condition? D. To avoid isoimmunization, get a vial of vitamin K
from the pharmacy and be ready to give an
A. Dehydration - sunken fontanel injection.
B. A normal finding
C. Increased intracranial pressure - bulging fontanel Situation:
D. Decreased intracranial pressure Nurse Adolf loves taking care of pediatric patients.
Pediatric nursing care demands a thorough
Closure: assessment so that good management may be
Anterior Fontanel - 12-18 mos - DIAMOND provided.
Posterior - 2-3 mos - TRIANGLE
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36. A newborn baby has been diagnosed with an D. Replacing the Logan bar carefully after cleaning
imperforate anus. How should Nurse Adolf explain this the incision
condition to the parents?
40. He is caring for a child diagnosed with Reye’s
A. The occurrence of fecal incontinence- encopresis
syndrome. He monitors for manifestations of which
B. Inadequate development of the anus
condition is associated with this syndrome?
C. Difficulty passing infrequent, dry stools
D. Folding of a portion of the intestine into the lower
A. Protein in the urine
bowel - intussusception
B. Symptoms of hyperglycemia
C. Increased intracranial pressure
37. Which nursing assessment findings indicate normal
D. A history of a staphylococcus infection
vital signs in a newborn infant?

A. Pulse, 112; respiratory rate, 24

B. Pulse, 124; respiratory rate, 28
C. Pulse, 144; respiratory rate, 48
D. Pulse, 164; respiratory rate, 55

Situation:
Growth and development refer to the physical,
cognitive, emotional, and social changes that occur
throughout an individual's lifespan. It encompasses
various aspects of human development, from infancy
to adulthood.

41. A 10-year-old child is newly diagnosed with type 1

38. Nurse Adolf teaches nursing students about diabetes mellitus. The nurse is planning for home care
mumps. Which clinical manifestation will the specialist with the child and the family and determines which is an
identify as the most common complication of this age-appropriate activity for health maintenance?
disease?
A. Administering insulin drawn up by an adult
A. Pain B. Self-administering insulin with adult supervision
B. Nuchal rigidity - aseptic meningitis [Link] independent decisions with regard to
C. Impaired hearing sliding-scale coverage of insulin
D. A red swollen testicle [Link] an adult assist in the self-administration of
insulin and glucose monitoring
39. Nurse Adolf is assigned to care for an infant on the
first postoperative day after a surgical repair of a 42. A home care nurse is providing instructions to the
cleft lip. Which nursing intervention is appropriate when mother of a toddler regarding safety measures in the
caring for this child’s surgical incision? home to prevent an accidental burn injury. Which
statement by the mother indicates a need for further
A. Rinsing the incision with sterile water after instruction?
feeding
B. Cleaning the incision only when serous exudate A. “I need to use the back burners for cooking.”
forms B. “I need to remain in the kitchen when I prepare
C. Rubbing the incision gently with a sterile meals.”
cotton-tipped swab
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C. “I need to be sure to place my cup of coffee on

Situation:
the counter.”
You have recently passed the PNLE and is now hired
D. “I need to turn the pot handles inward and to the
in a hospital. You started to review the fundamentals
middle of the stove.”

43. The nurse is reviewing the results of the rubella 46. What action should you take before performing a
venipuncture to
screening (titer) with a pregnant client. The test results
start continuous intravenous (IV) therapy?
are positive, and the client asks if it is safe for her
toddler to receive the vaccine. Which response by A. Apply a cool compress to the area. - vasocon
the nurse is most appropriate? B. Inspect the IV solution and check the expiration
date.
A. “Most children do not receive the vaccine until they C. Secure a padded armboard above the IV site. - after
are 5 years of age.” D. Apply a tourniquet below the venipuncture site.
B. “You are still susceptible to rubella, so your toddler - above site
should receive the vaccine.”
C. “It is not advised for children of pregnant women to 47. The doctor prescribes acetaminophen liquid 450 mg
be vaccinated during their mother’s pregnancy.” orally every 4 hours PRN for pain. The medication label
D. “Your titer supports your immunity to rubella, reads 160 mg/5 mL. You prepare how many milliliters
and it is safe for your toddler to receive the (mL) to administer one dose?
vaccine.”
A. 12 ML
44. The nurse is assigned to care for a hospitalized B. 15ML
toddler. Which measure should the nurse plan to C. 13ML
implement as the highest priority of care? D. 14ML

A. Providing a consistent caregiver

B. Protecting the toddler from injury
C. Adapting the toddler to the hospital routine
D. Allowing the toddler to participate in play and
diversional activities

45. A mother of a 3-year-old child asks the nurse what

personal and social developmental milestones she can
expect to see in her child. The nurse should tell the
mother to expect which findings? Select all that apply.
I. Begins problem-solving - too young
[Link] sexual curiosity
III. May begin to masturbate 48. You are sending an arterial blood gas (ABG)
IV. Notices gender differences specimen to the laboratory for analysis. What
V. Develops a sense of initiative- 4-5 y/o information should be included on the laboratory
[Link] positive self-esteem through skill requisition? Select all that apply.
acquisition - 6-8 y/o I. Ventilator settings
II. List of client allergies
A. I, II, III III. Client’s temperature
B. II, IV IV. Date and time the specimen was drawn
C. II, III, IV V. Any supplemental oxygen the client is receiving
D. II, III, V VI. Extremity from which the specimen was obtained

A. I, II, III
B. I, II, IV, V
C. I, III, IV, VI
D. I, III, IV, V

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49. Which arterial blood gas (ABG) values should you 52. You are anticipating rapid fluid replacement
anticipate in the client with a nasogastric tube therapy for the patient. With the previously identified
attached to continuous suction? percentage of burn injury, how much fluid should be
administered over the first 24 hours if the patient
A. pH 7.25, Paco2 55, HCO3 24 weighs 72 kg?
B. pH 7.30, Paco2 38, HCO3 20
C. pH 7.48, Paco2 30, HCO3 23 A. 9,072 mL
D. pH 7.49, Paco2 38, HCO3 30 - Metabolic Alka B. 7,776 mL
C. 13,968 mL
D. 15,552 mL
Suctioning: Alkalosis

50. For ensuring client safety, which assessment

should you prioritize before transitioning a client from
liquid to solid food?

A. Bowel sounds
B. Chewing ability
C. Current appetite
D. Food preferences

Situation:
An adult client is admitted to the emergency 53. A client who is brought to the emergency
department after a burn injury. department has experienced a burn covering greater
than 25% of his total body surface area (TBSA).
When reviewing the laboratory results drawn on the
51. The burn initially affected the upper half of the
client, which value should you most likely expect to
client’s anterior torso, and there were
note?
circumferential burns to the lower half of both of the
arms. The client’s clothes caught on fire, and the client
A. Hematocrit 65% (0.65) - hemoconcentration d/t
ran causing subsequent burn injuries to the entire
fluid shifting
face (anterior half of the head), and the upper half of
B. Albumin 4.0 g/dL (40 g/L)
the posterior torso. Using the rule of nines, the extent
C. Sodium 140 mEq/L (140 mmol/L)
of the burn injury would be what percent?
D. White blood cell (WBC) count 6000 mm3 (6 × 109/L)
A. 27%
54. The client is scheduled for hydrotherapy for a
B. 48.5%
burn dressing change. Which action should you take
C. 54%
to ensure that the client is comfortable during the
D. 31.5%
procedure?

A. Ensure that the client is appropriately dressed.

B. Administer an opioid analgesic 30 to 60
minutes before therapy. - improve comfort
C. Schedule the therapy at a time when the client
generally takes a nap.
D. Assign an unlicensed assistive personnel (UAP) to
stay with the client during the procedure.

Same w/ Chest tube removal: Give Paracet 30 mins

before.

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55. He receives a prescription for a regular diet. Which C. Persephone complex

is the best meal for you to provide to the client to D. Adolphus complex
promote wound healing?
59. The nurse observes an 8-year old child for any
A. Peanut butter and jelly sandwich, apple, tea signs of psychosexual development. What should
B. Chicken breast, broccoli, strawberries, milk they expect from this stage?
C. Veal chop, boiled potatoes, Jell-O, orange juice
D. Pasta with tomato sauce, garlic bread, ginger ale A. a time in which children’s libido appears to be
diverted into concrete thinking - LATENT PHASE
B. at the age where they want to fulfill their intimate
Situation:
desires
In every developmental stage, there are different
C. at the age where they are ready to learn how to
psychosexual stages a child must go through and
defecate by themselves
fulfill to meet its needs. As a healthcare professional
D. at the time where they will explore their own genitals
who values the holistic development of every
individual, nurse Jen provides appropriate
60. The nurse understands that Freud's phallic stage
interventions for each life stage.
of psychosexual development, which compares with
Erikson's psychosocial phase of initiative versus
56. She was asked by a first-time mom how she can guilt, is seen best at:
provide and meet the needs of her 3 month old
infant. She tries to fill the crib with toys, but her infant A. Adolescence
is not responding to it very well. What should she do? B. 6 to 12 years
C. 3 to 5 1/2 years
A. Place large, colorful teddy bears around the infant’s D. Birth to 1 year
crib
B. Provide safe and washable toys such as pacifier
- ORAL
C. Give brightly-colored building blocks to the infant
D. Give her infant a rattle for her to shake - 5 y/o

57. Toddlers exhibit signs of readiness for toilet

training. Which among the following are not included
as its criteria? (-)

A. Child is able to stay dry for 2 hours

B. Child is waking up dry from a nap
C. Child is able to sit, squat, and walk
D. Child is able to wear clothing by themselves

61. The nurse understands that problems with

dependence versus independence develop during
the sage of growth and development known as:
A. Infancy
B. School age
C. Toddlerhood
D. Preschool age

58. This type of attachment or complex is present 62. When planning to teach about the stages of growth
among pre-school children wherein the strong and development, what stage does the nurse indicate
emotional attachment of a preschool boy is present as basically concerned with role identifications?
towards the mother, and they usually tend to hate the
father. A. Oral stage
B. Genital stage
A. Electra complex C. Oedipal stage
B. Oedipus complex D. Latency stage
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67. May asks Nurse Nina to explain the reason why

63. The nurse incorporates play in interactions with PIH occurs. Nurse Nina's most appropriate answer
preschool-aged children, recognizing that play is would be:
essential for their emotional development in the
areas of: A. "An increase in blood volume to support the
growing child caused an increased pressure in
A. Projection the arteries causing damage to the walls. This
B. Introjection led to the blood vessels in the body to
C. Competition suddenly tighten up or get narrower, thus
D. Independence causing the blood pressure to shoot up."
- USE SIMPLE WORDS
64. The nurse understands that the resolution of the B. "Blood volume is increased by 40-50% in
Oedipus complex occurs when the child: pregnancy, which usually peaks at the 2nd
trimester due to an increase in plasma volume.
A. Rejects the parent of the same sex
That caused an increase in pressure in the
B. Adopts behaviors of both parents
endothelial lining of the arteries eventually leading
C. Identifies with the parent of the same sex
to vasospasm. Hypertension occurs due to the
D. Identifies with the parent of the opposite sex
narrowing of the blood vessels due to the spasms."
C. "The precise etiology revolves around aberrations
65. Surgery can be a very traumatic even for a child.
in vascular homeostasis, with dysregulation of
The nurse, when performing preoperative preparation,
endothelial function and vascular tone modulation
knows that according to Piaget's stages of cognitive
being paramount. This intricate cascade
development, children will experience the greatest fear
encompasses the intricate dance between
during the:
vasoconstriction-promoting factors and
vasodilation-mediating substances, leading to an
A. Sensorimotor stage
imbalance favoring heightened vascular resistance
B. Preoperational stage- Reality vs imagination
and augmented systemic arterial pressure."
C. Formal operational stage
D. "I am not sure if I am allowed to give details about
D. Concrete operational stage
that diagnosis. I will ask your physician to explain it
to you instead."

68. The nurse further assesses May for any other signs
while she interviews her in the clinic as she documents
the findings in May's chart. Which statement from May
would she record as possible evidence that May is
developing pre-eclampsia instead?

A. "I'm struggling to slip on my bedroom slippers

because my feet are so puffy at night."
B. "My mom taught me a lot of things about being
pregnant, but she never warned me that I would
always feel so tired."
66. Nurse Nina further assesses May. When BP was
C. "I've been having the desire to really take care of
taken at 11:00 am, the reading was at 140/80 mmHg.
how I look like these past few weeks."
She knows that the physician may confirm that May is
D. "The puffy feet are tolerable, but the swollen
developing PIH when which criterion is satisfied?
hands and wrists are not."
A. BP is at 130/90 mmHg at 12nn.
B. A BP reading is read to be 140/90 at 1:30 pm
C. 30/15 mmHg is added to the baseline BP at 7:00
pm.
D. BP is at 90/60 mmHg at 11:00 pm

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72. A patient is receiving intravenous lipid (fat

emulsion) therapy at home, managed by the patient's
spouse. During a visit, the Nurse Kate discusses the
potential side effects and adverse reactions of the
therapy with both the patient and the spouse. After the
discussion, she expects the spouse to understand that
the priority action in case of a suspected adverse
reaction is to:

A. Stop the infusion.

B. Contact the nurse.
C. Take the patient’s blood pressure.
D. Contact the local emergency response team.

73. Nurse Kate suspects that a client's spouse may be

69. Eventually, May's physician ordered magnesium experiencing caregiver strain. Which action should the
sulfate to be infused on piggyback with a loading dose nurse take to assess this condition?
of 5g to be infused slowly over 30 minutes and a
maintaining dose of 2 g/hr. Which of the following A. Refer the family to a social services agency.
symptoms, when observed by Nurse Nina, would B. Gather information from both the caregiver and
warrant her to discontinue the drug and notify the the client. - 2 SOURCES
physician? C. Wait for the caregiver to mention the stress.
D. Obtain feedback from the client about the caregiver.
A. An RR of 16 breaths per minute.
B. Urine output of 12 cc/hr. 74. Nurse Kate is educating a client newly diagnosed
C. BP 110/80. with diabetes mellitus about blood glucose
D. DTR of 2+ monitoring. The nurse should instruct the client to
report glucose levels that consistently exceed which
70. In case toxicity occurs, what emergency item must value?
Nurse Nina prepare at bedside?
A. 150 mg/dL (8.57 mmol/L)
A. Protamine sulfate - Heparin B. 200 mg/dL (11.42 mmol/L)
B. Atropine sulfate - Cholinergic crisis C. 250 mg/dL (14.28 mmol/L) - Possible DKA/HHS
C. Kalcinate - Cal gluconate D. 350 mg/dL (20.0 mmol/L)
D. Vitamin K - Warfarin
75. A client diagnosed with gastritis asks the Nurse
Situation: Kate about analgesics that won't cause epigastric
Health teaching is an essential nursing action to distress. She should recommend which medication?
ensure the continuity of care beyond the borders of
the institution. This helps promote independence to A. Aspirin - Gastric Irritant
each patient in managing their own health. B. Naproxen - Gastric Irritant
C. Ibuprofen- NSAIDs
D. Acetaminophen - WOF: Hepatotoxicity
71. Nurse Kate teaches a preoperative patient about
the nasogastric (NG) tube that will be inserted before
surgery. She concludes that the patient understands
when the tube will be removed postoperatively
based on which statement by the patient?

A. “When my doctor says so.”

B. “When I can tolerate food without vomiting.”
C. “When my gastrointestinal (GI) system is healed.”
D. “When my bowels start working again and I
begin to pass gas.”
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Situation:
79. Nurse Violet transfers to the NICU. She teaches
It is fulfilling for Nurse Violet to be a maternal and
handwashing techniques to the parents of an infant
child nurse. From health education to emergency
who is receiving antibiotic treatment for a neonatal
care interventions, in different stages of of
infection. She determines that the parents understand
pregnancy, labor and delivery, she performs her skills
the primary purpose of handwashing if they make which
effectively.
statement?

76. When should Nurse Violet she plan to begin A. “It is primarily done to reduce their fears.”
discharge planning to a mother with a preterm B. “It is primarily done to minimize the spread of
infant? infection to other siblings.”
C. “It is primarily done to allow them an opportunity to
A. When the mother is in labor communicate with each other and staff.”
B. When the discharge date is set D. “It is primarily done to reduce the possibility of
C. After the infant is stabilized during the early transmitting an environmental infection to the
stages of hospitalization infant.”
D. When the parents feel comfortable with and can
demonstrate adequate care for the infant 80. She is preparing to educate a teenage client about
sexuality. How will she start the teaching?
77. Nurse Violet is performing an assessment on a
primigravida client who has been a marathon runner A. Inform the teenager about the risks associated with
for several years. The client verbalizes concern pregnancy.
because she is no longer able to run in marathons B. Build a relationship and assess the teenager's
and is concerned about the brown discoloration on existing knowledge.
her face and her increasing size. Which statements C. Counsel the teenager to abstain from sexual activity
by the Nurse Violet are therapeutic? Select all that until marriage.
apply. D. Offer written materials concerning sexually
transmitted infections.
I. “I can see you’re disappointed at not being able to
run.”
Situation:
II. “Tell me how you are feeling about the changes in
Diabetes is one of the common, but also dangerous
your body.” III. “Don’t worry. Your body will go back to
diseases in life. It can also be present among
normal after delivery.”
pregnant women.
IV. “You need to ask your obstetrician about whether or
not you can run.”
V. “Wait and see. You will be back to marathon running 81. Charlotte is reviewing home care instructions with a
after delivery before you know it.” client who has type 1 diabetes mellitus and a history
VI. “Some of the changes in pregnancy are permanent of diabetic ketoacidosis (DKA). The client's spouse is
and that is the price that you have to pay for that bundle present during the instruction. Which statement by the
of joy.” spouse indicates that further teaching is needed? (-)

A. I, II A. “If he is vomiting, I shouldn’t give him any

B. II, III, IV insulin.”
C. I, III, V B. “I should bring him to the doctor if he develops a
D. I, V, VI fever.”
C. “If our grandchildren are sick, they probably
78. Which goal is most appropriate for postpartum shouldn’t come to visit.”
client who is at risk for uterine infection? D. “I should call the doctor if he has nausea or
abdominal pain lasting for more than 1 or 2 days.”
A. The client will verbalize a reduction of pain.
B. The client will report how to treat an infection.
C. The client will be able to identify measures to
prevent infection.
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82. Nurse Charlotte has conducted a class for pregnant B. A reading devoid of information concerning the
clients with diabetes mellitus about the signs and client's disease management.
symptoms of potential complications. She determines C. A low reading, indicating inadequate management of
that the teaching was effective if a client makes which blood glucose control.
statement? D. A high reading, indicating inadequate
management of blood glucose control.
A. “I should not have ultrasounds done because I am
diabetic.” NORMAL: <6%
B. “I’m glad I don’t have to worry about developing
hypoglycemia while I am pregnant.”
Situation:
C. “I need to watch my weight for any sudden gains
Good sexual and reproductive health is important for
because I could develop gestational hypertension.”
women's general health and wellbeing. It is central to
D. “My insulin needs should decrease during the last 2
their ability to make choices and decisions about
months because I will be using some of the baby’s
their lives, including when, or whether, to consider
insulin supply.”
having children.

83. Nurse Charlotte met with a postpartum patient who

is recovering from disseminated intravascular 86. You are discussing contraceptive options with a
coagulation. They will need to take low dosages of 32-year-old patient and she expresses "I want to have
anticoagulant medication. She advises them to avoid: children but not for a few years." You respond with the
(-) correct statement:

A. Brushing her teeth A. "If you do not become pregnant within the next few
B. Taking acetylsalicylic acid (aspirin) years, you never will."
- Increase bleeding risk B. "Women often have more difficulty becoming
C. Walking long distances and climbing stairs pregnant after about age 35."
D. All activities due to the risk of bruising injuries C. "Stop taking oral contraceptives several years before
you want to have a child."
84. Nurse Charlotte is educating a mother diagnosed D. "You have many more years of fertility left, so there
with diabetes mellitus who gave birth to a is no rush to have children."
large-for-gestational-age (LGA) infant about infant
care. She explains that LGA infants may appear more 87. A 28-year-old patient reports experiencing anxiety,
mature due to their size but often require stimulation for headaches with dizziness, and abdominal bloating
feeding and attachment. Which statement by the before her menstrual periods. What is the best
mother suggests the need for further teaching about course of action for you to take at this time?
infant care? (-)
A. Instruct the patient to track her symptoms in a
A. “I will talk to my baby when he is in a quiet, alert diary for 3 months. - establish baseline
state.” B. Recommend that the patient attempt aerobic
B. “I will allow my baby to sleep through the night exercise to alleviate her symptoms.
because he needs his rest.” C. Educate the patient about lifestyle adjustments to
C. “I will breast-feed my baby every 2½ to 3 hours and mitigate premenstrual syndrome (PMS) symptoms.
will use arousal techniques.” D. Counsel the patient to utilize nonsteroidal
D. “I will watch my baby closely because I know that he anti-inflammatory drugs (NSAIDs) like ibuprofen to
may not be as mature in his motor development.” manage symptoms.

85. She is observing a client with type 1 diabetes 88. A 19-year-old patient has received a diagnosis of
mellitus. Today's blood work reveals a glycosylated primary dysmenorrhea. How will you advise the
patient to address discomfort?
hemoglobin level of 10%. Based on this
result, she formulates a teaching plan, understanding
A. Refrain from engaging in aerobic exercise during
that it signifies which outcome?
menstruation.
B. Apply cold packs to the abdomen and back for pain
A. A normal reading, indicating effective management
relief.
of blood glucose control.
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C. Discuss with her healthcare provider the option of

starting antidepressant therapy. 93. A mother is unsure about breast-feeding her
D. Take nonsteroidal anti-inflammatory drugs newborn. His best response would be:
(NSAIDs) at the onset of her period.
A. “I’ll tell the nursery nurse that you want a bottle.”
B. “You have to decide immediately.”
89. While attending to a 58-year-old patient
C. “Let’s feed him by breast-feeding initially; I’ll
experiencing persistent menorrhagia, you will intend
help you.”
to oversee the:
D. “Breast-feeding is best; don’t even consider bottle
feeding.”
A. levels of estrogen.
B. complete blood count (CBC).
94. A mother took tetracycline during pregnancy for an
C. gonadotropin-releasing hormone (GNRH).
acne condition. She asks if there could be a problem
D. consecutive human chorionic gonadotropin (hCG)
with the baby. He responds that the baby could:
outcomes.

A. Be deaf
90. A 47-year-old patient inquires to you whether she is
B. Have discolored teeth
entering menopause after not having a menstrual
C. Be a slow learner
period for 3 months. What would be a suitable
D. Have webbed fingers and toes
response?

95. A couple comes to the clinic very excited because

A. "Have you considered hormone replacement
the woman missed her period 5 weeks ago. She is
therapy?"
experiencing early morning nausea, urinary
B. "Many women experience some sadness when
frequency, and fatigue. In anticipating questions about
entering menopause."
pregnancy, he would need to be aware that these are:
C. "What was your menstrual cycle like before your
periods ceased?"
A. Positive signs of pregnancy
D. "Given your age in the mid-40s, it's probable that
B. Probable signs of pregnancy
you're experiencing menopause."
C. Presumptive signs of pregnancy
D. Signs that also could indicate bladder infection
Situation:
Assessing the health of a newborn is very important
for detecting any problems in their earliest, most
treatable, stages. Nurse Colin is thorough yet quick
to make newborn assessments too be able to receive
prompt treatments
91. A client has just delivered a 6-lb 2-oz boy. She is
concerned about the way he looks. Nurse Colin, a
delivery nurse reassures the mother that a
pink body with purple feet and hands is a normal
condition called:

A. Acrocyanosis
B. Mongolian condition - normal skin discoloration
C. Sternal retractions - RDS
D. Patent ductus arteriosus - shunt did not close

92. A baby’s chin is quivering and he is trembling a little

post delivery. Colin replies to the mother that this is
probably due to a:

A. High sugar level - should be HYPO

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Situation:
The Duchess of Hastings is one of the important
clients in the Royal London Hospital. She is seeking
consultation for her current pregnancy.

96. At her first prenatal visit, a Daphne is being

interviewed by the nurse for her health history. She is
pregnant for the fourth time, has had one baby at 38
weeks’ gestation, premature twins at 35 weeks, and a 99. She is about 3 weeks larger in uterine size than
spontaneous abortion. How would the nurse her dates indicate. The physician orders an ultrasound
communicate this information to the healthcare team? to diagnose multiple fetuses. What information should
the nurse give the client in preparation for the test?
A. Gravida 4, para 3, a1
B. Gravida 4, para 2, T1, P2, A1, L3 A. “Do not eat or drink after midnight.”
C. Gravida 4, para 3, T1, P2, A1, L3 B. “Drink several glasses of water 1 hour before,
D. Gravida 4, para 2, T1, P1, A1, L3 and do not urinate.”
C. “Empty your bladder immediately before the test.”
D. “Give yourself an enema prior to the test.”

100. While assessing Daphne, another client is

wheeled in at the ER. She is at 35 weeks’ gestation in
labor with a diagnosis of abruptio placenta. What
pattern on the fetal monitor should the nurse
anticipate?

A. Late decelerations
B. Early decelerations
C. Variable decelerations
D. Accelerations with fetal movement
97. As part of a health history for pregnancy, she tells
the nurse that she is unsure of her blood type and Rh
factor. She had a spontaneous abortion at 10 weeks
and did not seek medical attention. After lab work, she
is found to have type O, Rh-negative blood. What
high risk factor should the nurse identify for the health
team?

A. The client may be at high risk for spontaneous

abortion.
B. The client may have become Rh sensitized
during her first pregnancy.
C. The client’s fetus may have CNS malformations due
to Rh incompatibility.
D. The client is at risk for noncompliance with prenatal
appointments.

98. Daphne further expresses that her LMP was June

10th. In order to determine her estimated delivery
date, what tool would the nurse use?

A. Nägele’s rule
B. McDonald’s rule
C. Hegar’s sign
D. Quickening
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