Situation.

As a community health nurse, it is essential to classify sick infants and

children through the use of IMCI.

1. Fast breathing is classified in a child aged 2 months to 12 months old if the respiratory
rate is:

*
1/1

A. 30 breaths per minute or more

B. 40 breaths per minute or more
C. 50 breaths per minute or more

D. 60 breaths per minute or more

2. What is the recommended drug of choice for treatment of pneumonia in children?

*
1/1

A. Cotrimoxazole
B. Amoxicillin

C. Ciprofloxacin
D. Azithromycin

3. A 4-year-old child presents with pus discharge from the ear for 16 days. What is the
correct treatment?

*
1/1
 A. Prescribe oral antibiotics for 5 days.
B. Refer urgently to the hospital for acute ear infection
C. Give paracetamol for pain.
D. Perform dry wicking and give quinolone ear drops for 14 days.

4. A child with diarrhea has sunken eyes, is restless, and has a skin pinch that goes back
slowly. What is the best management?*
1/1

A. Start rehydration using Plan B.

B. Begin intravenous fluids and refer urgently

C. Provide Plan A with ORS and food-based fluids at home
D. Administer zinc and antibiotics immediately

5. Which of the following is the appropriate management for a child living in a high-malaria
risk community with fever, stiff neck, and positive malaria test?

*
1/1

A. Give one dose of Paracetamol in clinic for high fever.

B. Administer rectal diazepam and observe for 24 hours.
C. Treat with oral antimalarial and send home with follow-up in 3 days if fever persists.
D. Administer artesunate and oral antibiotics, then refer urgently.

Situation. Understanding the menstrual cycle is necessary to fully grasp the concept
of fertilization.

6. What hormone surges to trigger ovulation around the midpoint of the menstrual cycle?
*
1/1

A. Estrogen
B. Progesterone
C. Luteinizing hormone

D. Follicle-stimulating hormone

7. A nurse assesses a patient who reports changing two pads in an hour for the past three
menstrual cycles. The nurse knows this condition is termed:

*
1/1

A. Menometrorrhagia
B. Menorrhagia

C. Metrorrhagia
D. Polymenorrhea

8. If progesterone levels remain elevated at the end of the luteal phase, what does this
indicate?

*
1/1

A. Pregnancy has likely occurred.

B. Fertilization did not occur, and menstruation will follow.

C. Estrogen levels are insufficient.
D. Ovulation did not occur.
9. Which hormone is primarily responsible for preparing the endometrium for
implantation during the luteal phase?

*
1/1

A. FSH
B. LH
C. Estrogen
D. Progesterone

10. What is considered as normal blood loss in a menstrual cycle?*

0/1

A. 10-40 mL

B. 40-70 mL
C. 80-110 mL
D. 110-140 mL

Situation. Early detection and prompt treatment is essential for a better prognosis.

11. Nurse IU teaches Yoona, a 21-year-old college student, how to perform BSE. Which
statement by Yoona indicates a need for further teaching?

*
1/1

A. BSE should be done annually beginning at the age of 20.

B. BSE is important for detecting changes in the breast tissue.

C. BSE can be performed while lying down or in front of a mirror.
D. BSE should be done even if there is no family history of breast cancer.
12. Which of the following is the most appropriate time for Yoona to perform her BSE?*
1/1

A. 3 days after menstruation

B. A week after menstruation

C. On the first day of menstruation

D. Any day during menstruation

13. All but one are recommended to have an annual Pap smear.*
1/1

A. A 21-year-old client who practices polygamy

B. A 30-year-old client with history of HPV infection
C. A 25-year-old client who has 2 consecutive negative smears

D. A 29-year-old client who smokes 1 pack of cigarette a day

14. Which of the following should be avoided before a Pap smear to ensure accurate
results?

*
1/1

A. Sexual intercourse within 24-48 hours of the test

B. Urinating right before the test

C. Drinking fluids on the morning of the test
D. Showering 12 hours before the test

15. Which of the following is the best time for a male to perform a testicular self-
examination?
*
1/1

A. After a hot shower

B. After sexual intercourse

C. Upon waking up
D. Any time during the day

Situation. Rai, a 32-year-old pregnant woman, is in her first trimester and is visiting
the clinic for her routine prenatal check-up.

16. According to Naegele’s Rule, what is Rai’s estimated date of delivery if her last
menstrual period was on August 15 – 18, 2024?

*
1/1

A. April 22, 2025

B. May 22, 2025

C. May 25, 2025

D. April 25, 2025

17. What germ layer gives rise to the reproductive system?

*
1/1

A. Bioderm
B. Mesoderm
 C. Endoderm
D. Ectoderm

18. The following are probable signs of pregnancy, except?

*
0/1

A. Fetal movement felt by examiner

B. Fetal movement felt by mother
C. Positive pregnancy test

D. Cervix softening

19. Rai asks why she sometimes feels faint while lying on her back. What advice should the
nurse provide to manage this condition?

*
1/1

A. “Always lie on your right side to improve blood flow."

B. "Elevate your head with pillows when lying on your back."
C. "Avoid lying flat on your back; try left lateral position instead."

D. "Drink more fluids to prevent dehydration."

20. Rai, a 25-year-old pregnant woman, is currently in her first trimester. She reports
having one previous full-term delivery who died shortly after, one miscarriage at 10 weeks,
and one child born at 32 weeks who is now alive and well. Using the GPTPAL system, how
should the nurse document Rai’s obstetric history?

*
0/1
 A. G3 P2 (T1 P1 A1 L2)
B. G4 P3 (T1 P1 A1 L1)

C. G4 P2 (T1 P2 A0 L1)
D. G4 P2 (T1 P1 A1 L1)

Situation. Nurse Gered is assigned to the obstetric ward and is currently reviewing
the various causes of bleeding during 1st semester of pregnancy to enhance his
clinical knowledge and provide effective care to his patients.

21. A client reports vaginal bleeding and cramping at 12 weeks gestation. The nurse notes
cervical dilation and effacement during assessment. Which type of abortion is this?

*
1/1

A. Inevitable abortion

B. Incomplete abortion
C. Threatened abortion
D. Complete abortion.

22. Which of the following is the most common site of implantation in an ectopic
pregnancy?

*
1/1

A. Isthmus
B. Ampulla

C. Interstitium
D. Fundus
23. A client with a confirmed ectopic pregnancy less than 3 cm in size is prescribed
methotrexate. Which of the following correctly describes the purpose of the medication?

*
1/1

A. Prevent uterine contractions

B. Shrink and destroy the products of conception

C. Induce uterine contractions for expulsion

D. Treat associated pelvic inflammatory disease

24. The nurse is assessing a patient with placenta previa who has experienced vaginal
bleeding. Which of the following findings requires immediate intervention?

*
1/1

A. Blood color is bright red

B. Fetal heart rate is 130 bpm
C. The patient reports no pain
D. Blood pressure decreases from 120/80 to 80/60 mmHg

25. The nurse is educating a patient on the follow-up care after treatment for Gestational
Trophoblastic Disease. Which statement by the patient indicates a need for further
teaching?*
0/1

A. "I will continue to monitor my HCG levels every 2-4 weeks until they return to normal."

B. "I can start trying for a pregnancy as soon as my HCG levels normalize."
C. "I will avoid pregnancy for at least one year."
D. "I should report any unusual symptoms, like excessive bleeding or abdominal pain."
Situation. Dingdong Gwantes wants to be a good father. He consulted his nurse
friend, Coco Martini about the different stages of growth and development.

26. Which of the following toys is most appropriate for an infant who is 6 months old?

*
1/1

A. Dollhouse with miniature furniture

B. PlayStation gaming console
C. A soft, washable rattle

D. Puzzle with small pieces

27. Which of the following is not a sign of readiness for toilet training?

*
0/1

A. Child is able to sit on toilet for 1 to 2 minutes without fussing or getting off
B. Child is able to to stay dry for 2 hours
C. Child recognizes urge to defecate or urinate
D. Child is able to sit, squat, or walk independently

28. A preschooler points at a table and says, “Wow, the table is color brown” without
recognizing that the table is broken. What cognitive characteristic of this stage is being
exemplified?*
1/1

A. Conservation
 B. Reversibility
C. Centering

D. Object permanence

29. A 2-year-old toddler is admitted for a severe respiratory infection. The nurse
recognizes that the toddler frequently says "no" and resists care. Which of the following is
the most appropriate nursing intervention to manage this behavior?

*
1/1

A. Use gentle restraint.

B. Ignore the toddler’s resistance and proceed with treatment.
C. Explain each procedure in detail to the child.
D. Provide choices.

30. A 6-year-old child frequently gets involved in group activities, such as sports and school
projects, and seeks praise from parents and teachers for doing well. However, when they
fail at a task, they feel discouraged and begin to doubt their abilities. According to Erikson,
which developmental stage is this?

*
1/1

A. Autonomy vs. Shame and doubt

B. Industry vs. Inferiority

C. Initiative vs. Guilt

D. Identity vs. Role Confusion

Situation. Nurse Seungkwan was assigned to a 34-year-old pregnant woman with

eclampsia.
31. Seungkwan is preparing to administer Digoxin. Which finding requires the nurse to
hold the medication and notify the provider?

*
0/1

A. Serum potassium level of 3.2 mEq/L

B. Apical pulse of 72 beats per minute

C. Urine output of 35 mL/hour

D. Blood pressure of 140/90 mmHg

32. The patient is on Magnesium Sulfate therapy. Which assessment finding suggests
magnesium toxicity?

*
1/1

A. Deep tendon reflexes +3

B. Respiratory rate of 10 breaths per minute

C. Blood pressure of 140/90 mmHg

D. Urine output of 40 mL/hr

33. Which laboratory result would cause the nurse to question continuing the
administration of MgSO4?

*
1/1

A. Serum magnesium level of 3.5 mEq/L

B. Serum potassium level of 3.8 mEq/L

C. Serum calcium level of 9.2 mg/dL
D. Serum sodium level of 135 mEq/L
34. Upon assessment, the patient who is on magnesium sulfate therapy develops
respiratory depression. Which medication should the nurse prepare to administer?

*
1/1

A. Naloxone
B. Digoxin
C. Hydralazine
D. Calcium gluconate

35. Seungkwan is educating the postpartum patient recovering from eclampsia. Which
statement by the patient indicates a need for further teaching?

*
1/1

A. “I will monitor my blood pressure regularly.”

B. “I should avoid high-sodium foods to help manage my blood pressure.”
C. “I don’t need to worry about seizures anymore since I’ve delivered.”

D. “I will report severe headaches or blurred vision immediately.”

Situation. A pregnant patient at 32 weeks presents with signs of PIH.

36. Which of the following is a hallmark feature of gestational hypertension?

*
1/1

A. Proteinuria of 1+
 B. Edema in the lower extremities
C. Blood pressure of 140/90 mmHg or higher after the 20th week AOG

D. Presence of visual disturbances

37. Which finding is most concerning in a 32-week pregnant patient diagnosed with severe
pre-eclampsia?

*
1/1

A. Blood pressure of 160/110 mmHg

B. Epigastric pain

C. Proteinuria +3
D. Weight gain of 1 lb. in one week

38. A nurse is teaching a patient with mild pre-eclampsia about dietary management.
Which statement indicates a need for further teaching?

*
1/1

A. “I will have my salt intake at 2-3 grams per day.”

B. “I need to avoid eating any salt-containing foods to avoid swelling.”

C. “I should monitor my weight gain weekly.”

D. “I will include fruits and vegetables in my meals.”

39. A patient with gestational hypertension is being educated about her condition. Which
statement by the patient indicates correct understanding?

*
1/1
 A. “This condition will resolve completely after delivery.”

B. “I need to avoid all salt in my diet.”

C. “Protein in my urine confirms my diagnosis.”
D. “I should stay active and avoid resting during the day.”

40. A patient with severe pre-eclampsia is receiving Magnesium Sulfate therapy. Which of
the following is the best indicator that the therapy is effective?

*
1/1

A. Blood pressure decreases to 130/80 mmHg

B. The patient reports no more epigastric pain
C. Deep tendon reflexes are absent
D. The absence of seizures is observed

Situation. FHR monitoring is an essential task of a nurse.

41. The nurse notes late decelerations on a fetal heart rate monitor. What is the most
appropriate nursing intervention?

*
1/1

A. Administer an oxytocin bolus.

B. Place the patient in a lateral position.

C. Increase the intravenous oxytocin drip rate.

D. Document the findings.
42. A nurse observes variable decelerations in the fetal heart rate. Which of the following is
the most likely cause?

*
1/1

A. Fetal movement
B. Uteroplacental insufficiency
C. Fetal cord compression

D. Fetal head compression

43. A patient receiving oxytocin for labor induction shows late decelerations on the FHR
monitor. What is the nurse's initial action?

*
1/1

A. Stop the oxytocin infusion.

B. Position the patient in a lateral position.

C. Provide supplemental oxygen.
D. Notify physician.

44. The nurse is caring for a laboring patient with recurrent variable decelerations. What
position is most effective in relieving cord compression?

*
1/1

A. Semi-Fowler’s
B. Trendelenburg

C. Lithotomy
D. Prone
45. A nurse observes early decelerations in the fetal heart rate during the second stage of
labor. What is the most appropriate nursing intervention?

*
0/1

A. Administer oxygen via face mask.

B. Reposition the patient to the left lateral position.

C. Monitor closely and document the findings.

D. Increase the oxytocin drip rate.

Situation: Nurse Lumi is educating a postpartum mother about the concept of lochia and
puerperium.

46. The postpartum patient at Day 8 is experiencing pinkish-brown vaginal discharge. What
is the most likely explanation for this finding?

*
1/1

A. Postpartum hemorrhage
B. Lochia Rubra
C. Lochia Serosa

D. Lochia Alba

47. Which statement by the patient indicates a need for further teaching?

*
1/1
 A. "I should expect to see lochia for up to 6 weeks after delivery."
B. "Lochia should be a yellowish color after the first few days."

C. "The color of lochia should progress from red to pink to white."

D. "If the lochia reverses in color, I should contact my doctor."

48. A postpartum patient undergoes a cesarean delivery. What is the expected lochia
pattern for this patient?

*
0/1

A. Lochia Rubra will be absent.

B. Lochia will follow the same pattern as a vaginal delivery.
C. Lochia will be significantly reduced in quantity.
D. Lochia will last longer than 6 weeks.

49. A 28-year-old primiparous woman, 2 days postpartum, is exhibiting passive behavior,

expressing fatigue and stating, "I can't seem to do anything right." Which phase of
puerperium is most likely being exhibited?

*
1/1

A. Taking-in phase

B. Taking-hold phase
C. Letting-go phase
D. Giving-up phase

50. Immediately after placental delivery, where should the nurse palpate the uterine
fundus?
*
0/1

A. Level of umbilicus

B. Halfway between umbilicus and symphysis pubis

C. Level of xiphoid process
D. Not palpable

Situation. Nurse Pedro is assigned to two patients – one with cleft lip and one with
cleft palate.

51. At what age is cleft palate repair (palatoplasty) typically performed to minimize speech
and feeding issues?

*
1/1

A. First few weeks of life

B. 2-4 months of age
C. 12-18 months of age

D. 3-4 years of age

52. Which of the following nursing interventions should be avoided in post-operative cleft
lip repair?

*
0/1

A. Allow the child to assume prone position.

B. Prevent the child from crying.
C. Position the child on supine.
 D. After feeding, cleanse suture line with NSS.

53. Which of the following is an appropriate post-operative intervention for a child who has
undergone cleft palate repair?

*
1/1

A. Allow the child to brush teeth gently within 24 hours.

B. Use soft elbow restraints to prevent touching the surgical site.

C. Resume regular diet with solid food.

D. Allow the child to lie flat for better comfort.

54. During assessment, which finding is most indicative of pyloric stenosis?

*
1/1

A. Olive-shaped mass in the left lower quadrant

B. Olive-shaped mass in the epigastrium, right of the umbilicus

C. Bulging abdomen and increased bowel sounds

D. Tenderness over the umbilical area

55. A nurse observes visible peristaltic waves in the epigastric region of an infant. When is
the best time to perform this assessment?

*
0/1

A. Immediately after vomiting

B. Right before feeding
 C. During or immediately after feeding
D. During crying

Situation. Nurse Kenaniah is reviewing different gastrointestinal disorders in

pediatric patients ahead of the May 2024 PNLE.

56. During health teaching of a patient with celiac disease, which statement indicates a
correct understanding of gluten sources?

*
0/1

A. "Oats are always safe as they do not contain gluten."

B. "Small amounts of rye are safe in a gluten-free diet."

C. "All dairy products must be eliminated to control symptoms."
D. "Rice and quinoa are excellent gluten-free alternatives."

57. Which of the following symptoms is most indicative of duodenal atresia in a neonate?

*
0/1

A. Persistent projectile vomiting after feeding

B. Early bilious vomiting with no abdominal distention
C. Abdominal distention with absence of bowel sounds

D. Non-bilious vomiting and palpable mass in the epigastrium

58. Which dietary recommendation is most appropriate for a child post-operatively for
Hirschsprung disease?
*
0/1

A. High-fiber, low-calorie diet

B. Gluten-free, low-fat diet

C. Low-fiber, high-calorie, high-protein diet
D. Dairy-free, high-fiber diet

59. What is the nurse’s priority action immediately after the birth of an infant with an
omphalocele?

*
1/1

A. Cover the sac with sterile gauze soaked in normal saline.

B. Wrap the sac in a dry, sterile dressing to minimize heat loss.

C. Administer IV antibiotics to prevent infection.
D. Position the infant prone to reduce pressure on the sac.

60. Which assessment finding strongly suggests imperforate anus in a newborn?

*
1/1

A. Failure to pass meconium within the first 24 hours of life

B. Absence of abdominal distention

C. Visible anal opening with no stool present
D. Weak but present "wink" reflex

Situation. Nurse Anna is conducting a physical assessment on a newborn.

61. A newborn’s palm is observed to have a single transverse palmar crease during physical
assessment. What condition does this finding suggest?

*
1/1

61. A newborn’s palm is observed to have a single transverse palmar crease during physical
assessment. What condition does this finding suggest?

*
1/1

A. Syndactyly
B. Polydactyly
C. Turner Syndrome
D. Trisomy 21

62. During Nurse Anna’s assessment, she notes that the newborn has a swollen vulva with
blood-tinged mucus secretion. What is the best action by Nurse Anna?

*
1/1

A. Report the finding as it may indicate trauma during delivery

B. Document the finding as a normal occurrence

C. Perform a culture to rule out infection

D. Apply a warm compress to reduce swelling

63. When assessing the newborn’s eyes, which finding requires further evaluation?
*
1/1

A. Strabismus persisting beyond 6 months of age

B. Subconjunctival hemorrhage resolving in 2–3 weeks

C. Eye color not fully established by 4 months of age
D. Absence of lacrimal duct maturation at birth

64. Nurse Anna observes a triangular-shaped fontanel on the posterior aspect of a

newborn’s head. What should the nurse document as the expected closure time for this
fontanel?

*
1/1

A. By 2-3 months of age

B. By 6-8 months of age

C. By 12-18 months of age
D. By 24 months of age

65. Nurse Anna is measuring the head circumference of a newborn and finds it to be 1 cm
larger than the chest circumference. This finding is most likely associated with:

*
1/1

A. Hydrocephalus
B. Microcephaly
C. Normal newborn anatomy

D. Macrocephaly
Situation. Nurse Killua wants to refresh his knowledge about Leopold’s maneuver, so
he decided to review his notes about the topic.

66. During the first maneuver, the nurse palpates a soft, irregular, and less mobile structure
in the uterine fundus. What is the most likely interpretation of this finding?

*
1/1

A. The fetus is in breech presentation

B. The fetus is in cephalic presentation

C. The fetus is in transverse presentation

D. The fetus is already engaged

67. During Leopold’s Maneuvers, the nurse determines that the fetus is in a cephalic
presentation with the fetal back on the maternal left side. In which location should the fetal
heart tones be auscultated?

*
1/1

A. Left upper quadrant

B. Right upper quadrant
C. Left lower quadrant

D. Right lower quadrant

68. Which of the following statements about Leopold’s Maneuver requires correction?
*
1/1

A. Leopold’s Maneuver 1 identifies the fetal presentation.

 B. Leopold’s Maneuver 2 determines the relationship of the fetal back to the uterus.
C. Leopold’s Maneuver 3 is performed with the nurse facing the patient’s head.
D. Leopold’s Maneuver 4 is performed with the nurse facing the patient’s feet.

69. During Leopold’s Maneuvers, the nurse detects a smooth and hard surface on the left
side and small irregular structures on the right side of the maternal abdomen. The nurse is
also hearing the fetal heart rate most clearly in the lower right quadrant. What is the most
likely fetal position?

*
0/1

A. Left occiput anterior (LOA)

B. Right occiput anterior (ROA)

C. Left occiput posterior (LOP)

D. Right occiput posterior (ROP)

70. The nurse performs the fourth maneuver and notes that the fetal head is sharply flexed,
with the occiput positioned anteriorly. What is the most favorable fetal attitude for
delivery?

*
1/1

A. Vertex

B. Military
C. Partial extension
D. Full extension

Situation. The first stage of labor starts from true contractions to full cervical
dilatation.
71. A woman in labor has cervical dilation of 2 cm with contractions that are mild in
intensity, lasting 30 seconds, occurring every 7 minutes. Which of the following is most
indicative of the phase of labor the patient is in?*
1/1

74. A client in labor reports feeling the urge to push but is only 7 cm dilated. What is the
appropriate nursing intervention?

*
1/1

A. Encourage the woman to push with each contraction to speed up labor.

B. Administer pain relief immediately to help the woman relax.
C. Instruct the woman to avoid pushing and focus on breathing techniques.

D. Prepare for immediate delivery since the urge to push has started.

75. Nurse Angela is monitoring a pregnant woman who is experiencing irregular

contractions that seem to stop when she ambulates. Upon examination, the cervix shows no
signs of dilation. What action should Nurse Angela take?

*
1/1

A. Monitor the contractions closely and prepare for delivery.

B. Administer medication to stimulate contractions.
C. Encourage the woman to rest and reassure her that this is likely false labor.

D. Initiate labor induction to speed up the process.

Situation. A 28-year-old pregnant patient with a diagnosis of eclampsia has been

admitted to the labor and delivery unit after experiencing a seizure. The patient is
receiving oxygen therapy to improve oxygenation and prevent complications.
76. Nurse Maria is preparing to administer oxygen to a patient with impaired gas exchange.
Which of the following is the most appropriate safety measure to take when using oxygen
therapy?

*
1/1

A. Ensure that no electrical devices are in use around the oxygen equipment.
B. Use woolen blankets to keep the patient warm.
C. Administer oxygen therapy with the highest flow rate.
D. Place a "No Smoking" sign on the patient's door and around the oxygen equipment.

77. Which of the following oxygen delivery systems provides the highest concentration of
oxygen?*
1/1

A. Nonrebreather mask

B. Nasal cannula
C. Simple face mask
D. Venturi mask

78. A patient receiving oxygen therapy via nasal cannula is complaining of dryness in the
nostrils. What is the best nursing intervention?

*
1/1

A. Increase the oxygen flow rate

B. Add a humidifier to the oxygen delivery system
 C. Switch to a face mask
D. Apply a cold compress to the nose

79. A patient on oxygen therapy has a history of severe allergic reactions to synthetic
fabrics. Which of the following materials should the nurse use for the patient’s blanket to
reduce the risk of static electricity?

*
1/1

A. Woolen blanket
B. Nylon blanket
C. Polyester blanket
D. Cotton blanket

80. The patient requires precise oxygen concentration. Which oxygen delivery system
should the nurse choose to ensure accurate oxygen administration?

*
1/1

A. Venturi mask

B. Nonrebreather mask
C. Partial rebreather mask
D. Nasal cannula

Situation. The nurse is tasked to perform reflex assessment in newborns.

81. The nurse is assessing a newborn's rooting reflex. Which of the following actions
indicates that the rooting reflex is intact?*
1/1

A. The newborn blinks in response to a bright light.

B. The newborn sucks on a pacifier placed in their mouth.
C. The newborn turns their head toward the side being touched near the mouth.

D. The newborn's toes fan out when the sole of the foot is stroked.

82. The nurse assesses a 3-month-old infant and observes the presence of a Moro reflex.
What does this finding most likely indicate?*
1/1

A. Normal development

B. Neurological impairment
C. Delayed reflex maturation
D. Hyperactive reflexes

83. The Babinski reflex is assessed by stroking the sole of the newborn’s foot. What finding
in a 2-week-old infant is expected?

*
1/1

A. Toes flex downward

B. Toes hyperextend and fan out

C. Leg withdrawal
D. No response

84. A nurse is assessing a newborn using the Galant reflex. Which finding would indicate a
normal response?

*
1/1

A. The newborn fans the toes.

B. The newborn extends the arms symmetrically.
C. The newborn flexes the trunk toward the side being stroked.

D. The newborn extends both legs alternately.

85. Which of the following reflexes typically persists throughout life?

*
1/1

A. Babinski reflex
B. Sucking reflex
C. Swallowing reflex

D. Plantar grasp reflex

Situation. Nurse Leonora is conducting a general skin inspection on a newborn.

86. Which of the following findings in a newborn would be most concerning and require
immediate evaluation?

*
1/1

A. Acrocyanosis persisting for 24–48 hours.

B. Central cyanosis noted on the trunk.

C. Erythema toxicum rash on the face and torso.

D. Mongolian spots on the lower back.
87. A newborn is noted to have a yellowish tint to the sclera and skin at 48 hours after
birth. What is the most likely cause of this condition?

*
1/1

A. Pathologic jaundice
B. Hyperbilirubinemia caused by breast milk
C. Physiologic jaundice

D. Obstructive jaundice

88. A term newborn presents with small, white papules on the nose and chin. What is the
most appropriate nursing intervention?

*
0/1

A. Educate parents to clean the area with mild soap and water.

B. Recommend the application of emollient cream.

C. Inform the parents that the condition is self-limiting and requires no treatment.
D. Suggest that parents avoid exposure to cold air to prevent worsening.

89. An Asian parent notices bluish patches on their newborn's lower back and buttocks.
What statement by the nurse is most appropriate?

*
1/1

A. "These are Mongolian spots, a normal finding that will likely fade over time."

B. "This discoloration suggests poor oxygenation and must be assessed further."

C. "This is a rare birthmark requiring specialist evaluation."
D. "This could be an allergic reaction to the bedding material."
90. A parent is asking about the Harlequin sign. Which of the following statements is
correct?

*
0/1

A. It occurs due to excessive blood flow to the upper side of the body.
B. It is a lifelong condition that requires treatment.

C. It can be resolved by changing the newborn's position.

D. It is an indicative sign of hemophilia.

Situation. Nurse Jai is reviewing mental health disorders in pediatric patients.

91. Trixie is diagnosed with autism spectrum disorder (ASD). When reviewing Trixie’s
chart, which of these symptoms does the nurse recognize as NOT appropriate with this
disorder?

*
1/1

A. Head banging
B. Absence of eye contact
C. Constant whirling around in a circle
D. Auditory hallucinations

92. Which of the following is a major concern when prescribing stimulant medications for
children with ADHD?
92. Which of the following is a major concern when prescribing stimulant medications for
children with ADHD?

*
1/1

A. Risk of developmental delay

B. Increased risk of suicidality
C. Potential for appetite suppression and weight loss

D. Risk of excessive sleepiness

93. Which of the following snacks is most appropriate for a child with ADHD?

*
1/1

A. Ice cream and cake

B. Gummy bears and chips
C. Fruit juice and chocolates
D. Whole grain crackers with cheese

94. A nurse is caring for a client with bulimia nervosa who is using laxatives frequently.
Which of the following should the nurse monitor for this client?

*
0/1

A. Metabolic acidosis
B. Metabolic alkalosis

C. Both
D. None of the above
95. A nurse is caring for a client with anorexia nervosa who is refusing to eat. Which of the
following responses is the most therapeutic?

*
1/1

A. "You need to eat to get better. It’s important for your recovery."
B. "I understand that you’re afraid of gaining weight, but let’s talk about how we can address this
together."

C. "You need to eat, or we’ll have to give you fluids through an IV. "
D. "Don’t worry, you’ll feel better after eating."

Situation. Nurse Arthur is revising his knowledge of diphtheria, pertussis, and

tetanus—the three critical diseases targeted by the DPT vaccine.

96. The nurse is educating a parent of a child with pertussis. Which statement by the parent
demonstrates the need for further teaching?

*
1/1

A. "I will ensure my child completes the full course of antibiotics."

B. "I will isolate my child until they are no longer contagious."
C. "I can give my child over-the-counter cough medicine to help with symptoms."

D. "I will watch for signs of dehydration and encourage frequent fluids."

97. What is the etiologic agent of diphtheria? *

1/1

A. Bacteria
 B. Virus
C. Fungi
D. Parasite

98. A patient receiving treatment for tetanus asks about the importance of tetanus toxoid
booster shots. Which response by the nurse is most appropriate?

*
1/1

A. "You need a booster shot every year to maintain immunity."

B. "A booster shot is recommended every 10 years to protect against tetanus."

C. "The tetanus booster shot is only necessary if you are exposed to soil or injuries."
D. "Receiving the initial vaccine series is enough to protect you for life."

99. Which clinical manifestation in a patient with tetanus should alert the nurse to the need
for immediate intervention?

*
0/1

A. Low-grade fever
B. Trismus
C. Lockjaw

D. Cyanosis

100. A nurse is preparing to administer DPT 2 to a child who experienced a convulsion

within 3 days of receiving DPT 1. What is the best course of action?

*
0/1
A. Administer DT instead of DPT.
B. Administer the DPT 2 vaccine and monitor the child closely for side effects.

C. Delay the vaccine until the child is 2 years old.

D. Administer only the tetanus toxoid component of the vaccine.