1. **A. A laceration that extends through the anal sphincter.

**
- A third-degree laceration involves the perineum and extends into the anal sphincter.

2. **C. "I will have to remain in bed until my due date comes."**
- Bed rest is often recommended in cases of placenta previa to prevent bleeding
complications.

3. **C. 12th week of pregnancy**

- By 12 weeks, the uterus rises out of the pelvis and expands into the abdomen.

4. **A. Frequency**
- Urinary frequency is common during the first trimester due to hormonal changes and
increased blood flow to the kidneys.

5. **B. 25–35 lbs**

- This is the recommended weight gain for a woman with a normal BMI during pregnancy.

6. **B. Modify preoperative teaching to meet the needs of either a planned or emergency
cesarean birth.**
- Teaching should be tailored based on whether the C-section is planned or an emergency.

7. **D. Convulsions**
- Convulsions are a sign of eclampsia, which is more severe than preeclampsia.

8. **C. Should be restricted because it may stimulate uterine activity.**

- Coitus may stimulate uterine contractions and should be avoided in cases of vaginal
bleeding.

9. **D. Assume Sim’s position.**

- Sim’s position helps reduce discomfort during labor by taking pressure off the back.

10. **A. The anterior fontanel is larger in shape compared to the posterior fontanel.**
- The anterior fontanel is larger and diamond-shaped, while the posterior is smaller and
triangular.

11. **B. 16–17 lbs**

- By 6 months, an infant typically doubles their birth weight, which would be around 13.6–14
lbs in this case.

12. **B. To promote uterine contraction**

- Oxytocin is administered post-delivery to stimulate uterine contractions and prevent
hemorrhage.

13. **B. 100 beats per minute**

 - A normal sleeping heart rate for a newborn ranges from 100 to 160 beats per minute.

14. **D. Trust vs. Mistrust**

- According to Erikson, infants first go through the Trust vs. Mistrust stage.

15. **A. Irreversible brain damage**

- Untreated phenylketonuria can lead to severe brain damage due to the accumulation of
phenylalanine.

16. **B. Preschool**

- Preschoolers are known for their vivid imaginations and often create imaginary friends.

17. **D. Saying “mama” or “dada” for the first time at 18 months of age**
- Saying "mama" or "dada" for the first time at 18 months could indicate a developmental
delay.

18. **C. Ignore her behavior as long as she does not hurt herself or others**
- Ignoring temper tantrums (unless harmful) helps avoid reinforcing negative behavior.

19. **B. 4 inches**

- A baby typically grows around 1 inch per month for the first 6 months, totaling about 4
inches by 4 months.

20. **D. Status asthmaticus**

- Status asthmaticus is a severe, persistent asthma attack that does not respond to standard
treatments.

21. **D. Abdominal mass and weakness**

- Nephroblastoma, or Wilms' tumor, typically presents with an abdominal mass and weakness
in children.

22. **A. Blurred vision**

- Blurred vision during pregnancy can indicate preeclampsia and should be reported
immediately.

23. **B. Irritability, purulent drainage in the middle ear, nasal congestion, and cough**
- These are common symptoms of acute otitis media in children.

24. **D. Kangaroo care**

- Skin-to-skin contact (kangaroo care) is an effective way to reduce stress in preterm infants.

25. **B. Use of a high-SPF sunblock**

- Individuals with albinism need high-SPF sunblock to protect their sensitive skin from UV 1.
Nurse Bella explains to a 28-year-old
pregnant woman undergoing a non-stress test
that the test is a way of evaluating the condition
of the fetus by comparing the fetal heart rate
with:
A. Fetal lie
B. Fetal movement
C. Maternal blood pressure
D. Maternal uterine contractions
2. During a 2-hour childbirth class focusing on
labor and delivery for primigravida, the nurse
describes the second maneuver that the fetus
goes through during labor progress when the
head is the presenting part as which of the
following:
A. Flexion
B. Internal rotation
C. Descent
D. External rotation
3. Mrs. Jovel Diaz went to the hospital for her
serum blood test for alpha-fetoprotein. The nurse
informed her about the result of the elevation of
serum AFP. The patient asked what the test was
for:
A. Congenital Adrenal Hyperplasia
B. PKU
C. Down Syndrome
D. Neural tube defects
4. Fetal heart rate can be auscultated with a
fetoscope as early as:
A. 5 weeks of gestation
B. 10 weeks of gestation
C. 15 weeks of gestation
D. 20 weeks of gestation
5. Mrs. Bendivin states that she is experiencing
aching swollen leg veins. The nurse would
explain that this is most probably the result of
which of the following:
A. Thrombophlebitis
B. PIH
C. Pressure on blood vessels from the
enlarging uterus
D. The force of gravity pulling down on the
uterus
6. Mrs. Ella Santoros is a 25-year-old
primigravida with a Rheumatic heart disease
lesion. Her pregnancy has just been diagnosed.
Her cardiac disease and functional capacity
classification is:
A. Class I
B. Class II
C. Class III
D. Class IV
7. The client asks the nurse, “When will this soft
spot at the top of my baby's head close?” The
nurse should instruct the mother that the
neonate’s anterior fontanel will normally close
by age:
A. 2-3 months
B. 6-8 months
C. 10-12 months
D. 12-18 months
8. When a mother bleeds and the uterus is
relaxed, soft, and non-tender, you can account
the cause to:
A. Atony of the uterus
B. Presence of uterine scar
C. Laceration of the birth canal
D. Presence of retained placenta fragments
9. Mrs. Pichie Gonzales’s LMP began April 4,
2010. Her EDD should be which of the
following:
A. February 11, 2011
B. January 11, 2011
C. December 12, 2010
D. November 14, 2010
10. Which of the following prenatal laboratory
test values would the nurse consider as
significant?
A. Hematocrit 33.5%
B. WBC 8,000/mm³
C. Rubella titer less than 1:8
D. One hour glucose challenge test 110 g/dL
11. Aling Patricia is a patient with preeclampsia.
Which statement indicates she has not
understood your instructions?
A. “I will restrict my fat in my diet.”
B. “I will limit my activities and rest more
frequently throughout the day.”
C. “I will avoid salty foods in my diet.”
D. “I will come more regularly for
check-ups.”
12. Mrs. Grace Evangelista is admitted with
severe preeclampsia. What type of room should
the nurse select for this patient?
A. A room next to the elevator.
B. The room farthest from the nursing station.
C. The quietest room on the floor.
D. The labor suite.
13. During a prenatal check-up, the nurse
explains to a client who is Rh negative that
RhoGAM will be given:
A. Weekly during the 8th month because this
is her third pregnancy.
B. During the second trimester, if
amniocentesis indicates a problem.
C. To her infant immediately after delivery if
the Coomb’s test is positive.
D. Within 72 hours after delivery if the infant
is found to be Rh positive.
14. A baby boy was born at 8:50 PM. At 8:55
PM, the heart rate was 99 bpm. She has a weak
cry, irregular respiration, and is moving all
extremities with slightly blue hands and feet.
The nurse should enter the APGAR score as:
A. 5
B. 6
C. 7
D. 8
15. Billy is a 4-year-old boy who has an IQ of
140. What does this mean?
A. Average normal
B. Very superior
C. Above average
D. Genius
16. A newborn is brought to the nursery. Upon
assessment, the nurse finds that the child has
short palpebral fissures and a thinned upper lip.
Based on this data, the nurse suspects that the
newborn is MOST likely showing the effects of:
A. Chronic toxoplasmosis
B. Lead poisoning
C. Congenital anomalies
D. Fetal alcohol syndrome
17. A priority nursing intervention for the infant
with cleft lip is which of the following:
A. Monitoring for adequate nutritional intake
B. Teaching high-risk newborn care
C. Assessing for respiratory distress
D. Preventing injury
18. Nurse Jacob is assessing a 12-year-old who
has hemophilia A. Which of the following
assessment findings would the nurse anticipate?
A. An excess of RBC
B. An excess of WBC
C. A deficiency of clotting factor VIII
D. A deficiency of clotting factor IX
19. Celine, a mother of a 2-year-old, tells the
nurse that her child “cries and has a fit when I
have to leave him with a sitter or someone else.”
Which statement would be the nurse’s most
accurate analysis?
A. The child has not experienced limit-setting
or structure.
B. The child is expressing a physical need,
such as hunger.
C. The mother has nurtured overdependence
in the child.
D. The mother is describing her child’s
separation anxiety.
20. Mylene Lopez, a 16-year-old girl with
scoliosis, has received an invitation to a pool
party. She asks the nurse how she can disguise
her impairment when dressed in a bathing suit.
Which nursing diagnosis can be justified by
Mylene’s statement?
A. Anxiety
B. Body image disturbance
C. Ineffective individual coping
D. Social isolation
21. The foul-smelling, frothy characteristic of
the stool in cystic fibrosis results from the
presence of large amounts of which of the
following:
A. Sodium and chloride
B. Undigested fat
C. Semi-digested carbohydrates
D. Lipase, trypsin, and amylase
22. Which of the following would be a
disadvantage of breastfeeding?
A. Involution occurs rapidly
B. The incidence of allergies increases due to
maternal antibodies
C. The father may resent the infant’s demands
on the mother’s body
D. There is a greater chance of error during
preparation
23. A client is noted to have lymphedema,
webbed neck, and low posterior hairline. Which
of the following diagnoses is most appropriate?
A. Turner’s syndrome
B. Down’s syndrome
C. Marfan’s syndrome
D. Klinefelter’s syndrome
24. A 4-year-old boy most likely perceives death
in which way:
A. An insignificant event unless taught
otherwise
B. Punishment for something the individual
did
C. Something that just happens to older
people
D. Temporary separation from the loved one.
25. Catherine Diaz is a 14-year-old patient on a
hematology unit being treated for sickle cell
crisis. During a crisis, aldosterone release is
stimulated. In what way might this influence
Catherine’s fluid and electrolyte balance?
A. Sodium loss, water loss, and potassium
retention
B. Sodium loss, water loss, and potassium
loss
C. Sodium retention, water loss, and
potassium retention
D. Sodium retention, water retention, and
potassium loss
damage.