- Nurse Divine took Sarah’s nursing health history as part of her assessment. Which of the following symptoms the patient experienced is classified as a presumptive sign of pregnancy?
A. Positive Hegar’s sign
B. Visualization of the fetus via ultrasound last week
C. Quickening felt by Nurse Divine
D. Amenorrhea which started 4 months ago
A. Positive Hegar’s sign - positive sign
B. Visualization of the fetus via ultrasound last week - positive sign
C. Quickening felt by Nurse Divine - positive sign
D. Amenorrhea which started 4 months ago
- To address Sarah’s complaint of frequent urination during her second trimester, Nurse Divine should advise her to:
A. Decrease her fluid intake, especially during the day
B. Drink more water, about three times the recommended amount, to prevent dehydration
C. Immediately report the symptom as it is always indicative of a urinary tract infection (UTI)
D. Limit her intake of fluids containing natural diuretics like coffee and tea
A. Decrease her fluid intake, especially during the day — NIGHT
B. Drink more water, about three times the recommended amount, to prevent dehydration
C. Immediately report the symptom as it is always indicative of a urinary tract infection (UTI)
D. Limit her intake of fluids containing natural diuretics like coffee
- Sarah asks Nurse Divine about the purpose or goal of the comprehensive prenatal assessment. Which of the following statements best reflects the primary goal of initial prenatal care?
A. To ensure the client strictly follows all the health workers’ advice to prevent any complications during labor and delivery
B. To accurately calculate the estimated date of confinement (EDC) using Naegele’s rule
C. To establish a baseline physical and psychosocial profile of the client and detect any potential risk factors
D. To immediately refer the client to a nutritionist for a personalized diet plan based on her current weight
A. To ensure the client strictly follows all the health workers’ advice to prevent any complications during labor and delivery
B. To accurately calculate the estimated date of confinement (EDC) using Naegele’s rule
C. To establish a baseline physical and psychosocial profile of the client and detect any potential risk factors
D. To immediately refer the client to a nutritionist for a personalized diet plan based on her current weight
- During the physical examination, Sarah is instructed to lie flat on the examination table. After a few minutes, she complains of dizziness/ nausea, and feeling faint. Which of the following is Nurse Divine’s immediate priority action?
A. Assess the client’s blood pressure and pulse rate
B. Offer a glass of water and encourage deep breathing
C. Elevate the client’s lower extremities to promote venous return
D. Turn the client onto her left side
A. Assess the client’s blood pressure and pulse rate
B. Offer a glass of water and encourage deep breathing
C. Elevate the client’s lower extremities to promote venous return
D. Turn the client onto her left side
Ratio: Supine hypotension
Situation: Sabrina is a 25-year-old pregnant woman rushed to the ER after her water broke at home just around an hour ago. She is accompanied by her husband, Barry, who seems supportive and cooperative. Nurse Tate promptly attended to the patient.
- Which of the following is the correct order of the cardinal movements of labor?
A. Descent, Extension, Internal Rotation, Flexion, External Rotation, and Expulsion
B. Descent, Flexion, Internal Rotation, Extension, External Rotation, and Expulsion
C. Descent, Internal Rotation, Flexion, Extension, External Rotation, and Expulsion
D. Descent, Flexion, Extension, Internal Rotation, External Rotation, and Expulsion
A. Descent, Extension, Internal Rotation, Flexion, External Rotation, and Expulsion
B. Descent, Flexion, Internal Rotation, Extension, External Rotation, and Expulsion
C. Descent, Internal Rotation, Flexion, Extension, External Rotation, and Expulsion
D. Descent, Flexion, Extension, Internal Rotation, External Rotation, and Expulsi
- Which of the following statements reflects the client’s understanding of the primary nursing concern after the rupture of membranes?
A. “I need to avoid drinking water now to prevent more fluid loss”
B. “There is nothing to be done after the rupture of membranes as it is a normal occurrence”
C. “My nurse will be checking my temperature and fetal heart rate frequently”
D. “I should immediately take a warm tub bath to ensure my perineum stays clean and to relieve pain”
A. “I need to avoid drinking water now to prevent more fluid loss”
B. “There is nothing to be done after the rupture of membranes as it is a normal occurrence”
C. “My nurse will be checking my temperature and fetal heart rate frequently”
D. “I should immediately take a warm tub bath to ensure my perineum stays clean and to relieve pain”
- Nurse Tate notes the following actions by Barry, Sabrina’s husband, during the active phase of labor . Which of the following requires the nurse’s immediate intervention?
A. Barry encourages Sabrina to use paced breathing during a contraction
B. Barry strokes Sabrina’s abdomen lightly for comfort
C. Barry gives Sabrina ice chips, as requested by the client
D. Barry discourages Sabrina to void as it may cause fastening of fetal descent
A. Barry encourages Sabrina to use paced breathing during a contraction (+)
B. Barry strokes Sabrina’s abdomen lightly for comfort (+)
C. Barry gives Sabrina ice chips, as requested by the client (+)
D. Barry discourages Sabrina to void as it may cause fastening of fetal descent (-) — cause DELAY
- Upon initial assessment, Nurse Tate notes that Sabrina’s contractions last 40 to 60 seconds and occur approximately every 3 to 5 minutes. Which statement best reflects the nurse’s analysis of Sabrina’s labor status based on these findings?
A. Sabrina is exhibiting signs of False Labor (Braxton Hicks) that will likely resolve with rest
B. Sabrina is likely in the Active Phase of the first stage of labor
C. Sabrina is experiencing a state of uterine hyperstimulation due to stress
D. Sabrina is transitioning into the Second Stage of labor
A. Sabrina is exhibiting signs of False Labor (Braxton Hicks) that will likely resolve with rest
B. Sabrina is likely in the Active Phase of the first stage of labor
C. Sabrina is experiencing a state of uterine hyperstimulation due to stress
D. Sabrina is transitioning into the Second Stage of labor
Situation: Nurse Hailey is assigned to patient Selena, who is a 33-year-old postpartum patient. She just gave birth to a healthy baby girl 6 hours ago in the hospital via normal spontaneous vaginal delivery. Selena is resting comfortably but is concerned about her abdominal shape and the constant need to breastfeed.
- Which of the following best describes the expected location of Selena’s uterine fundus 6 hours after delivery?
A. Two fingerbreadths below the symphysis pubis.
B. At the level of the umbilicus
C. Three fingerbreadths above the umbilicus
D. Halfway between the umbilicus and the symphysis pubis.
RATIO:
immediate: Midway between umbilicus & symphysis pubis
for 24 hours: level of umbilicus
1 day after: 1 cm or 1 finger breath/day
10th day: Non-palpable
A. Two fingerbreadths below the symphysis pubis.
B. At the level of the umbilicus
C. Three fingerbreadths above the umbilicus
D. Halfway between the umbilicus and the symphysis pubis.
RATIO:
immediate: Midway between umbilicus & symphysis pubis
for 24 hours: level of umbilicus
1 day after: 1 cm or 1 finger breath/day
10th day: Non-palpable
- Nurse Hailey assesses Selena’s fundus and finds it soft, boggy, and slightly higher than expected. Which action is the nurse’s immediate priority?
A. Notify the physician immediately
B. Obtain a full set of vital signs, especially the blood pressure
C. Encourage Selena to ambulate to the bathroom to void her bladder
D. Massage the uterine fundus until it is firm
A. Notify the physician immediately
B. Obtain a full set of vital signs, especially the blood pressure
C. Encourage Selena to ambulate to the bathroom to void her bladder
D. Massage the uterine fundus until it is firm
RATIO: Soft and boggy = uterine atony = massage
- Selena asks Nurse Hailey why she feels frequent, painful cramps when she breastfeeds. The nurse correctly analyzes that this discomfort is due to the release of which hormone?
A. Estrogen, causing cervical involution
B. Prolactin, stimulating milk production
C. Oxytocin, stimulating uterine contractions
D. Human Chorionic Gonadotropin (hCG), which is slowly being metabolized
A. Estrogen, causing cervical involution
B. Prolactin, stimulating milk production
C. Oxytocin, stimulating uterine contractions
D. Human Chorionic Gonadotropin (hCG), which is slowly being metabolized
- Nurse Hailey observes Selena spending time gazing at her baby, holding her closely, and frequently examining the baby’s fingers and toes. The nurse correctly documents this behavior as reflecting which phase of psychological adaptation?
A. Taking-hold phase
B. Letting-go phase action
C. Taking-in phase
D. Attachment phase
A. Taking-hold phase- shows interest
B. Letting-go phase - begins to initiate action
C. Taking-in phase
D. Attachment phase
- When assessing Mrs. Bongiovi’s neurological status every hour, which finding would the nurse prioritize documenting as a therapeutic and expected sign of adequate Magnesium Sulfate effect?
A. The client reports that the headache has completely resolved
B. Deep tendon reflexes (DTRs) are 1 + to 2+
C. Urine output has reached 200 mL per hour
D. The client’s urine protein levels reached normal levels
A. The client reports that the headache has completely resolved
B. Deep tendon reflexes (DTRs) are 1 + to 2+
C. Urine output has reached 200 mL per hour
D. The client’s urine protein levels reached normal levels - overall goal
RATIO:
Magnesium Sulfate = downers
↓BP
↓Urine Output
↓RR
↓Patella
- Mrs. Bongiovi asks Nurse Sadie,
“Why do I need to be in a quiet, dark room?” The nurse’s best explanation is that this environmental modification primarily aims to:
A. Decrease central nervous system (CNS) stimulation, thus preventing seizures
B. Prevent fluid retention and reduce edema, therefore lowering blood pressure
C. Promote better absorption of the Magnesium Sulfate infusion, as it is photosensitive
D. Minimize uterine contractions and prevent preterm labor by encouraging rest
A. Decrease central nervous system (CNS) stimulation, thus preventing seizures
B. Prevent fluid retention and reduce edema, therefore lowering blood pressure
C. Promote better absorption of the Magnesium Sulfate infusion, as it is photosensitive
D. Minimize uterine contractions and prevent preterm labor by encouraging rest
- During the assessment, Nurse Sadie notes that Mrs. Bongiovi’s urinary output has been 25 mL for the last two hours. The nurse should analyze this change as having the most immediate negative impact on the client’s treatment regimen by causing:
A. Decreased glomerular filtration rate, increasing the risk of chronic kidney disease
B. Increased uterine irritability, increasing the risk of abortion due to placental abruption
C. Reduced absorption of Magnesium Sulfate, increasing the blood pressure
D. Impaired excretion of Magnesium Sulfate, increasing the risk of toxicity
A. Decreased glomerular filtration rate, increasing the risk of chronic kidney disease
B. Increased uterine irritability, increasing the risk of abortion due to placental abruption
C. Reduced absorption of Magnesium Sulfate, increasing the blood pressure
D. Impaired excretion of Magnesium Sulfate, increasing the risk of toxicity
- Nurse Sadie assesses Mrs. Bongiovi’s vital signs and finds her respiratory rate is 9 breaths per minute. Which action should the nurse prioritize immediately after stopping the Magnesium Sulfate infusion?
A. Administer 1 gram of Calcium Carbonate intravenously via a slow push
B. Administer 1 gram of Calcium Gluconate intravenously via a slow push
C. Obtain a stat arterial blood gases to check for respiratory acidosis
D. Obtain a stat serum electrolytes to check for serum magnesium levels
A. Administer 1 gram of Calcium Carbonate intravenously via a slow push
B. Administer 1 gram of Calcium Gluconate intravenously via a slow push
C. Obtain a stat arterial blood gases to check for respiratory acidosis
D. Obtain a stat serum electrolytes to check for serum magnesium levels
RATIO: ANTIDOTE = CALCIUM GLUCONATE
- During the proliferative phase of the menstrual cycle, which of the following physiological changes is primarily occurring under the influence of estrogen?
A. The endometrium sloughs off, marking the beginning of a new cycle
B. The glands of the uterine endometrium become corkscrew in appearance
C. The endometrium thickens as much as eightfold
D. The corpus luteum in the ovary begins to regress
A. The endometrium sloughs off, marking the beginning of a new cycle - dec. Estrogen, dec. Progesterone = Menstruation
B. The glands of the uterine endometrium become corkscrew in appearance - luteal phase
C. The endometrium thickens as much as eightfold
D. The corpus luteum in the ovary begins to regress - Ischemic Phase
- A client who is tracking her Basal Body Temperature (BBT) to identify her fertile window shows her chart to Nurse Olivia. The nurse notes a slight dip in temperature by 0.5°F followed
by a sustained rise for the last three days. The nurse correctly analyzes this data as indicating that:
A. Ovulation has likely occurred and the client is currently in the luteal phase
B. The client is currently in the follicular phase and is about to ovulate
C. The client is experiencing an anovulatory cycle due to hormonal imbalance
D. The client is pregnant, since a sustained rise in temperature is the first sign of conception
A. Ovulation has likely occurred and the client is currently in the luteal phase - Inc. Progesterone
B. The client is currently in the follicular phase and is about to ovulate
C. The client is experiencing an anovulatory cycle due to hormonal imbalance
D. The client is pregnant, since a sustained rise in temperature is the first sign of conception
- Nurse Olivia is explaining the concept of autosomal recessive inheritance to a couple. Which statement by the nurse best describes this genetic pattern?
A. “Only one parent needs to carry the abnormal gene for the child to manifest the disorder”
B. “The disorder usually appears in every generation of the family tree.”
C. “Both parents must provide a copy of the abnormal gene for the child to have the disorder.”
D. “The disorder is carried only on the X chromosome and primarily affects males.”
A. “Only one parent needs to carry the abnormal gene for the child to manifest the disorder”
B. “The disorder usually appears in every generation of the family tree.”
C. “Both parents must provide a copy of the abnormal gene for the child to have the disorder.”
D. “The disorder is carried only on the X chromosome and primarily affects males.”
- A couple who has been unable to conceive for 14 months arrives for a fertility assessment. During the initial interview, the husband expresses hesitation, saying, “I think we should focus on my wife first, as infertility is usually a woman’s issue.” Which response by Nurse Maya is the
most appropriate and reflects an accurate evaluation of fertility assessment principles?
A. “You’re right, we usually start with the female partner because the tests are more comprehensive.
B. “Infertility is a shared concern, and both partners are evaluated together since male factors contribute to about half of infertility cases.”
C. “We can start with her, but if her tests are normal, we will eventually need to test you as well”.
D. “Infertility is stressful; perhaps we should focus on stress management before starting any
medical tests.
“
A. “You’re right, we usually start with the female partner because the tests are more comprehensive.
B. “Infertility is a shared concern, and both partners are evaluated together since male factors contribute to about half of infertility cases.”
C. “We can start with her, but if her tests are normal, we will eventually need to test you as well”.
D. “Infertility is stressful; perhaps we should focus on stress management before starting any
medical tests.
“
- Based on the Republic Act No. 10028 or the Expanded Breastfeeding Promotion Act of 2009, health and non-health facilities, establishments or institutions are mandated to establish”Lactation stations.” The following are requirements for these stations in the workplace except: (-)
A. Lavatory for handwashing, unless there is an easily-accessible lavatory nearby
B. Refrigeration or appropriate cooling facilities for storing expressed breastmilk
C. Electrical outlets for breast pumps
D. None of the above
A. Lavatory for handwashing, unless there is an easily-accessible lavatory nearby
B. Refrigeration or appropriate cooling facilities for storing expressed breastmilk
C. Electrical outlets for breast pumps
D. None of the above
- According to Section 28 of RA 9173 (Philippine Nursing Act of 2002), which of the following actions is within the legal scope of nursing practice during a normal delivery?
A. Internal examination during labor in the presence of antenatal bleeding and delivery
B. Suturing perineal lacerations, irregardless of special training acquired
C. Teach, guide and supervise students in the administration of nursing services
D. Administering oxytocin to induce labor based on the nurse’s independent judgment
A. Internal examination during labor in the presence of antenatal bleeding and delivery
B. Suturing perineal lacerations, irregardless of special training acquired
C. Teach, guide and supervise students in the administration of nursing services
D. Administering oxytocin to induce labor based on the nurse’s independent judgment
- Nurse Agatha is caring for Christie, a mother who adamantly refuses to have her baby undergo Newborn Screening (RA 9288) due to religious beliefs. How should Agatha analyze her legal and ethical responsibility in this situation?
A. Perform the screening regardless of the mother’s refusal, as the law mandates the test for all newborns to detect heritable conditions
B. Report the mother to the Department of Social Welfare and Development (DSWD) as the refusal constitutes a form of medical neglect
C. Facilitate a written acknowledgement of the mother’s understanding that refusal places the newborn at risk and ensure it is filed in the medical record
D. Secretly collect the blood sample while the mother is resting to ensure the infant is protected from undiagnosed metabolic disorders
A. Perform the screening regardless of the mother’s refusal, as the law mandates the test for all newborns to detect heritable conditions
B. Report the mother to the Department of Social Welfare and Development (DSWD) as the refusal constitutes a form of medical neglect
C. Facilitate a written acknowledgement of the mother’s understanding that refusal places the newborn at risk and ensure it is filed in the medical record
D. Secretly collect the blood sample while the mother is resting to ensure the infant is protected from undiagnosed metabolic disorders
- A 17-year-old unmarried Miss Marple arrives at the clinic for her first prenatal check-up. She begs Nurse Agatha not to tell her parents about her pregnancy. When evaluating this situation against the Code of Ethics for Filipino Nurses, what is the nurse’s priority action?
A. Notify the parents immediately as the patient is still a minor and they are the legal guardians.
B. Respect the patient’s right to confidentiality and autonomy while encouraging her to seek support from a trusted adult
C. Inform the patient that as a nurse, Agatha is legally obligated to report all teenage pregnancies to the local health office
D. Refuse to provide care until the patient brings a parent or guardian to sign the consent form
A. Notify the parents immediately as the patient is still a minor and they are the legal guardians.
B. Respect the patient’s right to confidentiality and autonomy while encouraging her to seek support from a trusted adult
C. Inform the patient that as a nurse, Agatha is legally obligated to report all teenage pregnancies to the local health office
D. Refuse to provide care until the patient brings a parent or guardian to sign the consent form
