1.
The average Filipino birth weight is:
Correct Answer
A. 3,000 grams (3 kilograms or 6.6 pounds)
Explanation
The average Filipino birth weight is 3,000 grams (3 kilograms or 6.6 pounds). This means that most babies born in the Philippines have a weight close to 3 kilograms or 6.6 pounds.
2.
Upon measuring the anthropometric measurement of a newborn baby, you are aware that the normal head, chest and abdominal circumference of the child is/are:
Correct Answer
B. Head circumference (HC): 33-35 centimeters, chest circumference (CC): 31-33 centimeters, abdominal circumference (CC): 31-33 centimeters.
Explanation
The correct answer is the second option because it provides the most accurate and appropriate range of measurements for the head, chest, and abdominal circumference of a newborn baby. These measurements fall within the normal range for a healthy newborn, indicating that the baby's growth and development are on track.
3.
Mrs. Cruz a mother of a 2 months old child asks you about when will the soft depressions on the head of her baby is close. As a nurse, you are aware that:
Correct Answer
A. The anterior fontanels of the baby will be expected to be closed at around 12-18 months, while the posterior fontanels will be closed 2-3 months.
Explanation
The correct answer states that the anterior fontanels of the baby will be expected to be closed at around 12-18 months, while the posterior fontanels will be closed 2-3 months. This means that the soft depressions on the baby's head, known as fontanels, will gradually close over time. The anterior fontanel is the larger and diamond-shaped soft spot on the top of the baby's head, while the posterior fontanel is the smaller and triangular soft spot at the back. It is important for the fontanels to close as it indicates the normal development of the baby's skull bones.
4.
The nurse assesses the vital signs of a newbon infant with respiratory rate of 35 breaths/ minute. Based on this finding, which action is appropriate?
Correct Answer
C. Document the findings.
Explanation
Based on the given information, the nurse assesses the respiratory rate of a newborn infant to be 35 breaths per minute. This respiratory rate falls within the normal range for a newborn, which is typically between 30-60 breaths per minute. Therefore, there is no immediate need for intervention such as administering oxygen or notifying the physician. Instead, the appropriate action would be to document the findings for future reference and reassess the respiratory rate in 15 minutes to ensure it remains stable.
5.
A nurse is monitoring a 3-month-old infant for signs of increased intracranial pressure. On palpation of the fontanels, the nurse notes that the anterior fontanel is soft and flat. Based on this finding, which nursing action is appropriate?
Correct Answer
C. Document the finding.
Explanation
Based on the nurse's finding of a soft and flat anterior fontanel, it indicates that the infant does not have increased intracranial pressure. Therefore, there is no immediate need for intervention such as increasing oral fluids or notifying the physician. The appropriate action in this situation would be to document the finding for future reference and monitoring.
6.
The nurse is caring for a 6 lb 7 oz baby girl delivered two hours ago. Which of the following observations of the infant, if made by the nurse, is expected?
Correct Answer
D. The infant has fine crackles and a respiratory rate of 44
7.
Vitamin K is a fat-soluble vitamin necessary for:
Correct Answer
C. Blood coagulation during the 1st week of life
Explanation
Vitamin K is necessary for blood coagulation during the 1st week of life. This means that it helps in the formation of blood clots, which is important for preventing excessive bleeding. Newborn babies have low levels of vitamin K, and their bodies are still developing the ability to produce it on their own. Therefore, it is crucial to provide them with vitamin K supplementation to ensure proper blood clotting.
8.
Newborns are at risk for bleeding disorders. They are being Vit K in the IM route at birth. The nurse should assess the following as signs of bleeding in an infant, except:
Correct Answer
B. Increased hemoglobin & hematocrit
Explanation
The correct answer is "Increased hemoglobin & hematocrit." Hemoglobin and hematocrit levels typically increase in response to bleeding or blood loss, so an increase in these levels would not be a sign of bleeding in an infant. Black, tarry stools, hematuria, and bleeding from open wounds are all signs of bleeding and should be assessed in an infant receiving Vitamin K.
9.
Nurse Judy is assessing child’s reflexes. She is trying to identify different neonatal reflexes. She observed that when an infant’s mother strokes her newborn’s cheek, the baby turns his head in that direction, this reflex is known as:
Correct Answer
B. Rooting
Explanation
When an infant's mother strokes the newborn's cheek and the baby turns his head in that direction, it is called the rooting reflex. This reflex is a natural instinct for the baby to turn their head and search for the source of touch or stimulation, usually in order to find the mother's breast for feeding. The rooting reflex is present in newborns and helps them locate the source of nourishment.
10.
When nurse Judy places her index finger in the child’s palm, the child’s fingers close momentarily, this reflex is described as:
Correct Answer
A. Palmar Grasp
Explanation
When nurse Judy places her index finger in the child's palm and the child's fingers close momentarily, this reflex is described as the Palmar Grasp. This reflex is a natural response in infants where they automatically grasp objects that touch their palms. The Palmar Grasp reflex is present from birth and gradually disappears as the child grows and develops better control of their hand movements.
11.
Baby Francis, eight day old neonate, delivered by normal spontaneous delivery is about to be roomed-in to his mother. The nurse instructs the mother how to take the temperature of Baby Francis. Her teaching is effective when the mother takes the neonate’s temperature:
Correct Answer
A. Under his arm
Explanation
The correct answer is "Under his arm." This is because taking a temperature under the arm, also known as axillary temperature, is a safe and non-invasive method for measuring the body temperature of a neonate. It is commonly used for infants and young children as it is easy to perform and less uncomfortable compared to other methods such as oral or rectal temperature measurements.
12.
Francis’ mother asks how the cheesy substance covering his buttocks and lower extremities can be removed. Which of the following is the MOST APPROPRIATE advice of the nurse?
Correct Answer
D. Allow it to remain on the skin because it is a protective coating
13.
When Jocelyn is administering an intramuscular injection of antibiotic to an infant, which among the following is the BEST site?
Correct Answer
D. Vastus Lateralis muscle
Explanation
The vastus lateralis muscle is the best site for administering an intramuscular injection of antibiotic to an infant. This muscle is located on the lateral side of the thigh and is well-developed in infants, making it a safe and accessible site for injections. Additionally, the vastus lateralis muscle has a thick muscle belly with minimal nerves and blood vessels, reducing the risk of injury or complications during the injection.
14.
In assessing for the respiratory system of the newborn infant you are aware that normally the infant has:
Correct Answer
A. Gentle, quiet, rapid but shallow, largely diapHragmatic and abdominal respiration.
Explanation
The correct answer is "Gentle, quiet, rapid but shallow, largely diaphragmatic and abdominal respiration." This answer is correct because it accurately describes the normal respiratory pattern of a newborn infant. Newborns typically have a gentle and quiet breathing pattern, with rapid but shallow breaths that are mainly controlled by the diaphragm and abdominal muscles. This respiratory pattern is a normal adaptation to life outside the womb and helps to ensure efficient gas exchange in the newborn.
15.
In assessing the cardiovascular system of the infant, as a nurse you are also aware that the pulse of the infant is best determine in:
Correct Answer
B. The apical pulse is recommended since the radial pulses are not ordinarily palpable.
Explanation
The correct answer is that the apical pulse is recommended since the radial pulses are not ordinarily palpable. This is because in infants, the radial artery is often difficult to palpate due to its small size and the amount of subcutaneous fat present. The apical pulse, which is located at the apex of the heart, can be easily auscultated using a stethoscope and provides a more accurate assessment of the infant's heart rate.
16.
The appearance of newborn with pink body but has bluish color of the arms and legs is known for?
Correct Answer
B. Acrocyanosis
Explanation
Acrocyanosis is a condition characterized by a pink body color in newborns with bluish discoloration of the arms and legs. It is caused by the temporary constriction of blood vessels in the hands, feet, and extremities, leading to reduced blood flow and oxygenation in these areas. This condition is considered normal in newborns and typically resolves on its own within a few days or weeks. Circumoral cyanosis refers to bluish discoloration around the mouth, while central cyanosis is a more serious condition characterized by bluish discoloration of the lips, tongue, and trunk.
17.
During the 5th minute APGAR , the nurse assesses for?
Correct Answer
B. Adaptation to environment
Explanation
During the 5th minute APGAR, the nurse assesses for adaptation to the environment. This means that the nurse will evaluate how well the newborn is adjusting to its surroundings outside of the womb. This assessment includes observing the baby's heart rate, respiratory effort, muscle tone, reflex irritability, and color. It helps determine if the baby is transitioning well and if any immediate interventions or further monitoring are necessary.
18.
Before doing perilight theraphy in your client in the OB ward, the nurse should know the rationale of removing any rubber or plastic materials on client prior to perilight therapy because:
Correct Answer
C. They are good conductors of heat
Explanation
The reason for removing rubber or plastic materials on the client prior to perilight therapy is that rubbers and plastic materials are good conductors of heat. This means that if they are left on the client during the therapy, they can transfer heat from the therapy device to the client's skin, potentially causing burns or discomfort. By removing these materials, the nurse ensures that the therapy is conducted safely and effectively.
19.
In doing perineal care to a male client, a nurse retracts the foreskin of the uncircumsized client. She noted that there is a presence of a white-creamy substance known as:
Correct Answer
D. Smegma
Explanation
Smegma is the correct answer. Smegma is a white-creamy substance that can accumulate beneath the foreskin of an uncircumcised male. It is a mixture of dead skin cells, oils, and other bodily fluids. It is important for nurses to retract the foreskin during perineal care to ensure proper hygiene and prevent the buildup of smegma, which can lead to infections if not cleaned regularly.
20.
One procedure you can perform during bag technique, is Benedict’s Test. What is the main purpose of this test?
Correct Answer
B. To check for the presence of glucose in the urine
Explanation
Benedict's Test is used to check for the presence of glucose in the urine. This test is based on the principle that glucose in the urine can reduce copper sulfate to form a colored precipitate. By performing this test, healthcare professionals can determine if a person has high levels of glucose in their urine, which can be an indication of conditions such as diabetes. Therefore, the main purpose of Benedict's Test is to detect the presence of glucose in the urine.
21.
MpleThe indication once a client yield a positive result to Acetic Acid test includes the appearance of ______________ in the test tube?
Correct Answer
C. Haziness
Explanation
When a client yields a positive result to the Acetic Acid test, the appearance of haziness in the test tube indicates the positive result. This haziness may be due to the presence of certain substances in the urine, such as crystals or sediment, which can cause the urine to appear cloudy or hazy. This can be an indication of certain medical conditions or abnormalities in the urinary system.
22.
The following are roles and responsibilities of a Public Health Nurse during home visit which among them is a dependent nursing action?
Correct Answer
B. Cure the client and give prescription of drugs
Explanation
The role of a Public Health Nurse during a home visit is to provide preventive and educational healthcare services to individuals and families. This includes scheduling appointments for future visits, documenting and recording observations and care rendered. However, curing the client and giving prescriptions of drugs is not within the scope of a Public Health Nurse's responsibilities. This is typically done by a medical doctor or a nurse practitioner.
23.
As a public health nurse, it is essential to know the significance of using the bag technique in caring for clients in the community. All but one are correct purposes of using the Bag technique:
Correct Answer
D. It assures that all needed interventions will be provided by the nurse
Explanation
The Bag technique does not assure that all needed interventions will be provided by the nurse. While the Bag technique is important for organizing and containing necessary articles for client care, preventing the spread of infection or contamination, and saving time and effort for the nurse, it does not guarantee that all interventions will be provided. The nurse's knowledge, skills, and ability to assess and prioritize client needs are crucial in ensuring that all necessary interventions are provided.
24.
The following are important points to consider in doing the bag technique except:
Correct Answer
D. All materials used shall be placed in the bag after care
Explanation
The correct answer is "All materials used shall be placed in the bag after care." This statement is not a point to consider in doing the bag technique. It is not necessary to place all materials used in the bag after care. The bag technique primarily focuses on cleaning the contents of the bag, protecting them from contact with any articles in the client's home, and arranging them conveniently for the nurse.
25.
After assisting a NSD, during the 3rd stage of labor and delivery, the nurse identifies the shiny part of the placenta that detaches starting from the middle throught the edges as:
Correct Answer
C. Schultze
Explanation
During the 3rd stage of labor and delivery, the nurse identifies the shiny part of the placenta that detaches starting from the middle through the edges as Schultze.
26.
You are a student nurse on duty in a lying in clinical in the community health center, Lady Lee, 29 year old client consult for check up. She is concerned that she is pregnant for the second time. You asked Lady Lee her LMP which she stated as last July 25, 2009. The date she consulted for the check up was September 2, 2009. When is Lady Lee's EDD? (Write the complete M-DD-YEAR ex.December 12, 2009)
Correct Answer
May 2, 2010
May 02, 2010
Explanation
The correct answer is May 2, 2010 or May 02, 2010. To calculate the estimated due date (EDD), you need to add 9 months and 7 days to the first day of the last menstrual period (LMP). In this case, Lady Lee's LMP was on July 25, 2009. Adding 9 months brings us to April 25, 2010, and then adding 7 days gives us May 2, 2010.
27.
What is the importance of credes prophylaxis to newborns?
Correct Answer
A. For prevention of gonorrheal conjunctivitis
Explanation
Credes prophylaxis is important for newborns because it helps prevent the transmission of gonorrheal conjunctivitis. This condition, also known as ophthalmia neonatorum, is a severe eye infection that can cause blindness if left untreated. Credes prophylaxis involves the application of antibiotic eye drops or ointment to the newborn's eyes shortly after birth, which helps kill any bacteria that may be present and prevent the development of the infection. This preventive measure is crucial in protecting the newborn's vision and overall health.
28.
Inside the delivery room while birth and delivery, the nurse correctly instructs the mother to:
Correct Answer
D. A and B
Explanation
During birth and delivery, the nurse correctly instructs the mother to push during contractions and use purse-lip breathing. Pushing during contractions helps to facilitate the delivery of the baby by applying pressure to the birth canal. Purse-lip breathing involves taking slow, deep breaths in through the nose and exhaling through pursed lips, which helps the mother to stay calm and control her breathing during labor. Therefore, options A and B are the correct instructions given by the nurse.
29.
After the delivery of the head it is essential that you:
Correct Answer
C. Suction using the bulb syringe
Explanation
After the delivery of the head, it is important to suction using the bulb syringe. This is done to clear the baby's airway of any amniotic fluid or mucus that may be present, which can help prevent respiratory distress and ensure proper breathing. Suctioning the baby's airway is a standard procedure in neonatal care and is crucial for the baby's well-being and overall health.
30.
As a nurse it is essential that we determine the signs of placental separation. All but one are signs of placental separation:
Correct Answer
D. Cullen's sign