SITUATION :

Aling Julia, a 32 year old fish vendor from baranggay matahimik came to see
you at the prenatal clinic. She brought with her all her three children. Maye, 1 year 6
months; Joy, 3 and Dan, 7 years old. She mentioned that she stopped taking oral
contraceptives several months ago and now suspects she is pregnant. She cannot
remember her LMP.

1. Which hormone is necessary for a positive pregnancy test?

A. Progesterone
B. HCG
C. Estrogen
D. Placental Lactogen

A. HCG is responsible for positive pregnancy test. But it is NOT a positive sign of
pregnancy. Only PROBABLE. Purpose of HCG is to maintain the secretion of
progestrone by the corpus luteum. It will deteriorate by 2nd trimester as the placenta
resumes its funciton.

2. With this pregnancy, Aling Julia is a

A. P3 G3
B. Primigravida
C. P3 G4
D. P0 G3

She has 3 children, so para 3. Since she is pregnant, this is her 4th gravida.
Remember that even if the pregancy is beyond the age of viability [ >7 months ]
consider it as PARA and not GRAVIDA as long as the baby is still inside the uterus.

3. In explaining the development of her baby, you identified in chronological order of

growth of the fetus as it occurs in pregnancy as

A. Ovum, embryo, zygote, fetus, infant

B. Zygote, ovum, embryo, fetus, infant
C. Ovum, zygote, embryo, fetus, infant
D. Zygote, ovum, fetus, embryo, infant

The Ovum is the egg cell from the mother, the sperm will fertilize it to form a
zygote. This usually happens in the AMPULLA or the distal third of the fallopian tube.
The zygote is now termed as an embryo once it has been implanted. Implantation
takes 3-4 days. When the embryo reach 8th weeks, it is now termed as a FETUS
until it has been delivered and then, neonate then infant.
4. Aling Julia states she is happy to be pregnant. Which behavior is elicited by her
during your assessment that would lead you to think she is stressed?

A. She told you about her drunk husband

B. She states she has very meager income from selling
C. She laughs at every advise you give even when its not funny
D. She has difficulty following instructions

Stressed is manifested in different ways and one of them, is difficulty following

instructions. Telling you that her husband is drunk and has meager income from
selling is not enough for you to conclude she is stressed. Assessment is always based
on factual and specific manifestations. A diagnosis is made from either ACTUAL or
POTENTIAL/RISK problems.
A and B are both potential problems, but not actual like D. C is automatically
eliminated first because laughing is not indicative of stress.

5. Which of the following statements would be appropriate for you to include in Aling
Julia's prenatal teaching plan?

A. Exercise is very tiresome, it should be avoided

B. Limit your food intake
C. Smoking has no harmful effect on the growth and development of fetus
D. Avoid unnecessary fatigue, rest periods should be included in you
schedule

Exercise is not avoided in pregnancy, therefore eliminate A.

Food is never limited in pregnancy. Calories are even increased by around 300 cal a
day as well as vitamins and minerals. B.
Smoking, alcohol and drug use are avoided for the rest of the pregnancy because of
their harmful effects on the growth and development of the fetus. C

Rest period and avoiding unnecessary fatigue is one of the pillars in health teaching
of the pregnant client. D.

6. A factor in infertility maybe related to the PH of the vaginal canal. A medication

that is ordered to alter the vaginal PH is:

A. Estrogen therapy
B. Sulfur insufflations
C. Lactic acid douches
D. Na HCO3 Douches

Sperm is innately ALKALINE. Too much acidity is the only PH alteration in the vagina
that can kill sperm cells. Knowing this will direct you to answering letter D. Sodium
Bicarbonate douches will make the vagina less acidic because of it's alkaline
property, making the vagina's environment more conducive and tolerating to the
sperm cells. D.
Estrogen therapy will not alter the PH of the vaginal canal. A.
Sulfur insufflation is a procedure used to treat vaginal infections. B
Lactic acid douches will make the vagina more acidic, further making the
environment hostile to the alkaline sperm. C
SITUATION :
Alpha, a 24 year old G4P3 at full term gestation is brought to the ER after a
gush of fluid passes through here vagina while doing her holiday shopping.

7. She is brought to the triage unit. The FHT is noted to be 114 bpm. Which of the
following actions should the nurse do first?

A. Monitor FHT ever 15 minutes

B. Administer oxygen inhalation
C. Ask the charge nurse to notify the Obstetrician
D. Place her on the left lateral position

Remove A. A FHR of 114 bpm is 6 beats below normal. Though monitoring is

continuous and appropriate,
This is not your immediate action. B, Oxygen inhalation needs doctor's order and
therefore, is a DEPENDENT nursing action and won't be your first option.
C is appropriate, but should not be your IMMEDIATE action.

D. The best action is to place the client on the LEFT LATERAL POSITION to decrease
the pressure in the inferior vena cava by the gravid uterus thereby increasing venus
return and giving an adequate perfusion to the fetus. Your next action is to call and
notify the obstetrician.

8. The nurse checks the perineum of alpha. Which of the following characteristic of
the amniotic fluid would cause an alarm to the nurse?

A. Greenish
B. Scantly
C. Colorless
D. Blood tinged

A greenish amniotic fluid heralds fetal distress not unless the fetus is in breech
presentation and pressure is present on the bowel.
Other color that a nurse should thoroughly evaluate are : Tea colored or strong
yellow color that indicates hemolytic anemia , as in RH incompatibility.

9. Alpha asks the nurse. "Why do I have to be on complete bed rest? I am not
comfortable in this position." Which of the following response of the nurse is most
appropriate?

A. Keeping you on bed rest will prevent possible cord prolapse

B. Completed bed rest will prevent more amniotic fluid to escape
C. You need to save your energy so you will be strong enough to push later
D. Let us ask your obstetrician when she returns to check on you

Once the membrane ruptures, as in the situation of alpha, The immediate and most
appropriate nursing diagnosis is risk for injury related to cord prolapse. Keeping the
client on bed rest is one of the best intervention in preventing cord prolapse. A

Once the amniotic fluid escapes, It is allowed to escape. Although bed rest does
saves energy, It is not the most appropriate response why bed rest is prescribed
after membranes have ruptured. Not answering the client's question now will
promote distrust and increase client's anxiety. It will also make the client think that
the nurse is incompetent for not knowing the answer.

10. Upon examination by the obstetrician, he charted that Alpha is in the early stage
of labor. Which of the following is true in this state?

A. Self-focused
B. Effacement is 100%
C. Last for 2 hours
D. Cervical dilation 1-3 cm

A. The earliest phase of labor is the first stage of labor : latent phase characterized
by a cervical dilation of 0-3 cm, Mild contraction lasting for 20 to 40 seconds. This
lasts approximately 6 hours in primis and 4.5 hours in multis.

B. Effacement of 100% is a characteristic of the TRANSITION PHASE as well as being

self focused.

C is the characteristic of ACTIVE PHASE of labor, Characterized by a cervical dilation

of 4-7 cm and contractions of 40 to 60 seconds. This phase lasts at around 3 hours
in primis and 2 hours in multis.
SITUATION :
Dervid, A registered nurse, witnessed an old woman hit by a motorcycle while
crossing a train railway. The old woman fell at the railway. Dervid Rushed at the
scene.

1. As a registered nurse, Dervid knew that the first thing that he will do at the scene
is

A. Stay with the person, Encourage her to remain still and Immobilize the leg while
While waiting for the ambulance.
B. Leave the person for a few moments to call for help.
C. Reduce the fracture manually.
D. Move the person to a safer place.

The old woman is in the middle of a train railway. It is very unsafe to immobilize
here legs and remain still at the middle of a railway considering that a train might
come anytime while waiting for an ambulance. Safety is the utmost importance at
this point. If letter D is not among the choices and the situation is a little less
dangerous, the answer will be A. Remember that in all cases of emergencies,
removing the victim from the scene to a much safer place is a priority.

3. The old woman complains of pain. John noticed that the knee is reddened, warm
to touch and swollen. John interprets that this signs and symptoms are likely related
to

A. Infection
B. Inflammation
C. Thrombophlebitis
D. Degenerative disease

B. After a trauma, Inflammation will start almost instantly.

A. Infection occurse 24-48 hours after bone fracture and not immediately.
C. Thrombophlebitis occurs within 4 to 7 days of hospitalization after prolonged
immobilization.
D.There is no evidence that the client has a degenerative disease and degenerative
diseases will manifest in variety of ways and not after a trauma.

4. The old woman told John that she has osteoporosis; Dervid knew that all of the
following factors would contribute to osteoporosis except

A. Hypothyroidism
B. End stage renal disease
C. Cushing’s Disease
D. Taking Furosemide and Phenytoin.

B,C,D all contributes to bone deminiralization except HYPOTHYROIDISM.

Hyperthyroidism will contribute to bone deminiralization as well as
Hyperparathyroidism due to the increase in PTH, It will cause the movement of
calcium from the bone to the blood causing HYPERCALCEMIA. ESRD will cause
increase in PHOPHSATE due to its poor excretion. The amount of phosphate is
inversely proportional to the amount of calcium. Cushing disease promotes bone
demineralization as well as medications like diuretics and anti convulsants.
SITUATION: James, A 27 basketball player sustained inhalation burn that required
him to have tracheostomy due to massive upper airway edema.

5. Wilma, His sister and a nurse is suctioning the tracheostomy tube of James. Which
of the following, if made by Wilma indicates that she is committing an error?

A. Hyperventilating James with 100% oxygen before and after suctioning

B. Instilling 3 to 5 ml normal saline to loosen up secretion
C. Applying suction during catheter withdrawal
D. Suction the client every hour

This is unecessary. Suctioning is done on PRN basis and not every hour. A,B and C
are all correct processes of suctioning a tracheostomy.

6. Which of the following method if used by Wilma will best assure that the
tracheostomy ties are not too tightly placed?

A. Wilma places 2 fingers between the tie and neck

B. The tracheotomy can be pulled slightly away from the neck
C. James’ neck veins are not engorged
D. Wilma measures the tie from the nose to the tip of the earlobe and to the xiphoid
process.

Wilma should place 2 fingers underneath the tie to ensure that it is not too tight nor
too loose.
Letter D is the measurement for NGT insertion and is unrelated to tracheostomy.

SITUATION : Juan Batumbakal was diagnosed with Acute Close Angle Glaucoma. He
is being seen by Nurse Jet.

7. What specific manifestation would nurse Jet see in Acute close angle glaucoma
that she would not see in an open angle glaucoma?

A. Loss of peripheral vision

B. Irreversible vision loss
C. There is an increase in IOP
D. Pain

D.There is NO PAIN in open angle glaucoma. Pain is absent because the increase in
intra ocular pressure is not initiated abruptly. It is gradual and progressive and will
lead to unoticed loss of peripheral vision. Pain is present in acute close angle
glaucoma because there is a sudden closure or narrowing of the canal of schlemm.

A,B,C are all present in both glaucomas including the low pressure glaucoma.
8. Peachy was rushed by his father, Steven into the hospital admission. Peachy is
complaining of something buzzing into her ears. Nurse Budek assessed peachy and
found out It was an insect. What should be the first thing that Nurse Budek should
try to remove the insect out from peachy’s ear?

A. Use a flashlight to coax the insect out of peachy’s ear

B. Instill an antibiotic ear drops
C. Irrigate the ear
D. Pick out the insect using a sterile clean forceps

Lights can coax the insect out of the child's ear. This is the first measure employed in
removing a live insect from the childs ear.
Insects are not removed ALIVE, therfore, C and D are both wrong.
B. Antibiotics has no effects since the child do not have any infection. If the insect
did not come out after coaxing it with light, 2nd measure employs instillation of
diluted alcohol or a mineral oil to kill the insect which is then removed using letter D.

SITUATION : Mr. Franco, 70 years old, suddenly could not lift his spoons nor speak
at breakfast. He was rushed to the hospital unconscious. His diagnosis was CVA.

9. Which of the following is the most important assessment during the acute stage of
an unconscious patient like Mr. Franco?

A. Level of awareness and response to pain

B. Papillary reflexes and response to sensory stimuli
C. Coherence and sense of hearing
D. Patency of airway and adequacy of respiration

Airway is always a priority in an unconscious client. Refer to maslows hierarchy of

needs for prioritization. ABC (airway, breathing and circulation)

10. If Mr. Franco’s Right side is weak, what should be the most accurate analysis by
the nurse?

A. Expressive aphasia is prominent on clients with right sided weakness

B. The affected lobe in the patient is the Right lobe
C. The client will have problems in judging distance and proprioception
D. Clients orientation to time and space will be much affected

A. If the client's right side is weak, the affected lobe is the LEFT LOBE which is where
the broca's area is located. Client will exhibit expressive aphasia, careful and slow
movements and right sided weakness.
B. is eliminated, affected lobe is the LEFT LOBE
C. Judging distance and proprioception is usually impaired in clients with RIGHT
sided stroke.
D. Telling that the clients orientation to time and space will be much affected is a
blind shot analysis. This is seen on clients with severe and massive hemorrhagic
stroke with recovery failure related to aneurysms producing long term and
permanent coma. Mr. Franco right side is weak, not paralysed, therefore some
functions are still left intact.