COLEGIO DE SAN LORENZO DE RUIZ MANILA, INC

College of Nursing
Competency Appraisal 1
Preliminary Examination (Part 1)

Name: ____________________________________________________ Date: ______________________

Directions: ENCIRCLE THE BEST ANSWER for the given situations. STRICTLY NO ERASURES AND/OR ALTERATIONS.

I. Clinical Scenario 1: Case Analysis

Ms. LQ, 18 years of age came in the Emergency Room with a complaint of sudden abdominal pain at the
Right Lower Quadrant accompanied by episodes of loose bowel movement. “Biglang sumakit ang tiyan
ko”, “maraming beses na din ako dumumi”. She also added that she hasn’t taken any meal or fluids
because she is afraid that it will aggravate the pain and increase the episodes of LBM. She is unable to
walk upright and needed to be assisted by her mother. Her vital signs were taken and revealed that she
was also febrile. She was referred to the ER resident for further evaluation and management.

1. As the Emergency Room Nurse, you are to assess Ms. LQ: You know that you have to gather
data to apply the most appropriate nursing care. You know that pain experienced by the patient
can be assessed best by gathering covert data, such as:
a. Inspection, Auscultation, Percussion and Palpation
b. Vital Signs and Pain Scale
c. Patient’s Feeling, sensation and perception.
d. Inspection and Interview
2. Based on your interaction with the patient, which of the following data is classified as covert
data:
a. The patient’s vital signs which is in the above scenario suggest that she is febrile.
b. The complaint of the patient of sudden abdominal pain at the RLQ accompanied by
episodes of LBM.
c. The patient’s statement of “Biglang sumakit ang tiyan ko”.
d. The observation of the nurse that the patient is unable to walk upright and needed to be
assisted by her mother.
3. You are to use Pain Scale to assess the pain of the patient, Pain Scale is what kind of Data:
a. Subjective
b. Objective
c. Subjective Data transformed into Objective Data
d. Both Subjective and Objective Data
4. By mere observation alone of the patient, upon her/ his arrival, the nurse can document an
overt data that can support the statement of the patient that she is in pain.
a. Patient’s verbalization of the pain and its location.
b. Patient’s gait, facial expression and behavior.
c. Blood Pressure, Temperature, Respiratory & Pulse Rate Rate
5. As a nurse you know that to ensure a comprehensive data gathering, primary assessment
methods should be implemented, which includes:
a. Inspection, Auscultation, Percussion and Palpation
b. Observing, Interview, Examining
c. Cephalocaudal Examination
d. Utilization of Nursing Conceptual Models
6. There are various sources of data that can be gathered during assessment, you are aware that if
you desire to compare your data with norms and standards, a source that you should consult/
refer?
a. Support people
b. Client’s records
c. Other health care professionals
d. Related literature
7. As a nurse you know that the BEST definition of the Nursing Process is:
a. A methodical, balanced method of planning and providing tailored nursing care.
b. A systematic, rational method of planning and providing universal nursing care.
c. A systematic, sensible method of planning and providing standard nursing care.
8. Which BEST characterizes the Nursing Process?
a. Client-centered, universally applicable & an adaptation of problem-solving and systems
theory.
b. Direct, multidisciplinary & universally applicable.

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 c. It requires variety of interpersonal, technical and intellectual skills, behavioral analysis.
9. Which part of the nursing process has a purpose of identifying client strength and health
problems that can be prevented or resolved by collaborative and independent nursing
interventions.
a. Planning
b. Diagnosis
c. Assessment
d. Implementing
10. To develop an individualized care strategy that specifies client goals/ expected outcomes and
related nursing interventions is the purpose of which phase of the nursing process?
a. Planning
b. Diagnosis
c. Assessment
11. In organizing your gathered data, you are aware that one vital tool is the utilization of
conceptual models. If you are to organize the data of the patient at the presented scenario, (if
ever that you will gather necessary data to create a nursing care plan) what will be BEST
conceptual model to be used?
a. Nursing Conceptual Models such as Orem’s Self-Care Model
b. Non-Nursing Conceptual models such as Maslow’s Hierarchy of Needs
c. Wellness model such as Health history
12. What BEST describes the PLANNING PHASE of the nursing process?
a. Inputs from clients and support persons are considered essential.
b. A deliberate, systematic phase of the nursing process that involves observation, analysis
and risk assessment.
c. The most important part of the nursing process since this is where the implementation
of the nursing knowledge and skills can be implemented.
13. Based on the given scenario, what is the BEST nursing diagnosis?
a. Fluid Volume Deficit: Intake Insufficient to replace fluid loss related to episodes of loose
bowel movement
b. Acute Pain r/t to increased gastrointestinal motility as evidenced by episodes of loose
bowel movement and vomiting.
c. Ineffective Tissue Perfusion related to hypovolemia as evidenced by episodes of loose
bowel movement
14. To formulate a short term goal for your identified priority nursing diagnosis (at question no. 13),
which of the following planning statement BEST describe your vision?
a. After 8 hours of nursing intervention, the patient will no longer have episodes of
vomiting and loose bowel movement.
b. After 8 hours of nursing intervention, the patient will be able to demonstrate fluid
replacement interventions every episode of fluid loss.
c. After 8 hours of nursing intervention, patient will verbalize lessening of experienced
pain from a pain scale of 10 to a pain scale of 7.
15. In the PLANNING PHASE, strategies to be utilized can be BEST selected through which criteria?
a. It should be congruent with what is universally accepted.
b. It should reflect utilization of resources that is ideal, standard and prescribed.
c. It should be based on nursing knowledge and experience.

II. Care of the Expecting Mother and the Unborn

16. Probable signs of pregnancy involve all, EXCEPT:

a. Chadwick sign, Ballottement, increased abdomen size and height.
b. Positive serum and pregnancy test home kit
c. Morning sickness, easy fatigability, dizziness
17. Mrs. MS, 18 years old, confirmed her pregnancy through ultrasound, she is 18 weeks pregnant,
she feels that she is not ready for the new role of motherhood. She feels that she is too young
and that she has a lot of things to accomplish. This emotional reaction to the pregnancy is
referred to as:
a. Denial
b. Anger
c. Grief
18. Mrs. GG, 38 years of age, G6;P5, 18 weeks AOG, was scheduled for her routine prenatal check-
up and was assigned to your care. After being seen by her doctor, she confided to you that her
husband would like to be intimate with her despite her being pregnant. As a nurse, your BEST
response would be:

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 a. You should tell your husband that he should respect your space during the entire phase
of pregnancy and sexual intercourse is out of the picture. Sexual intercourse can cause
infection that can be harmful to your baby.
b. What your husband feels is normal and if you would like to engage in sexual activities I
don’t see anything wrong. Anyway, its completely safe and is not contraindicated
considering that you have been pregnant many times. Once or twice of sexual
intercourse won’t hurt anyone right?
c. I see no problem if you and your husband will engage in sexual activity, as long as you
consented to it. However, I suggest you consult this matter to your doctor for her to
assess if any complications will be aggravated if you have sexual intercourse with your
husband.
19. During a health teaching activity, a mother asked about the decrease immune response of the
body during pregnancy. How do you explain this occurrence?
a. This occurrence varies and depends on the immunity of the mother. Some mothers have
low production of IgG and should be careful during the entire course of the pregnancy
since they are prone to infection and this can bring harm to the growing fetus.
b. The decrease in the immunologic response is normal. The Immunoglobulin G (IgG)
production is particularly decreased. This is the body’s way to ensure that its own
immunologic response will not turn against the fetus. In this decrease of CD4 level the
WBC increases to compensate.
c. The decrease in the immunologic competency is normal occurrence due to the decrease
in Immunoglobulin IgA and IgM that is a response to a growing fetus. It avoids conflict
between the immune response of the mother and the child. In this decrease of CD4
level the WBC increases to compensate.
20. All are included in Department of Health’s Essential Health Care Services for Mothers and
Unborn, EXCEPT:
a. Antenatal registration, Tetanus toxoid immunization, Clean and safe delivery
b. Nutrition and supplementation, Dental care, Essential Newborn Care
c. Family Planning, STD/HIV Prevention, Promotion of Breastfeeding
21. All are Components of the Health History during Prenatal Care, EXCEPT:
a. Demographic Data, History of Past & Present Illness, History of Family Illness
b. Gynecologic History, Obstetric History, Review of Systems
c. Demographic Data, Chief Concern, Family Profile, Social History, Obstetric History
22. Tetanus Toxoid immunization is part of the services offered for mothers during prenatal care,
the nurse knows that if a mother is given TT2 the period of protection will be?
a. 5 years
b. 3 years
c. 1 year
23. You also know that the timing of administration for TT2 should be:
a. At least three months after TT1 or during subsequent pregnancy
b. At least four weeks after TT1 within the same pregnancy
c. At least six weeks after TT1 within the same pregnancy
24. Fourth dose of Tetanus Toxoid is given to pregnant or would be pregnant mother, this gives
them how many years of immunity:
a. 10 years
b. 5 years
c. 12 years
d. None of the above
25. A nurse should educate pregnant mothers that 5 doses of Tetanus Toxoid ensures that their
baby are conveyed a duration of protection equivalent to:
a. 5 years
b. 5 months
c. 10 months
d. Lifetime immunity
26. High-risk sexual behavior, poverty, substance abuse and domestic violence are social behavioral
factors that indicates High Risk Pregnancy.
a. True
b. False
c. Neither True or False
27. Vaginal bleeding, Pregnancy Induced Hypertension (HIP), Urinary Tract Infection (UTI) and
persistent vomiting are signs indicating complications of pregnancy.
a. True
b. False
c. Either A or B

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 28. Signs of true labor includes: Lightening, Uterine Contractions and ruptures of the membrane.
a. True
b. False
c. Either A or B
29. Two pelvic measurements are important to determine the adequacy of the pelvic size, one is the
transverse diameter of the outlet and what is the other one?
a. The diagonal conjugate (the anteroposterior diameter of the inlet).
b. The horizontal conjugate (the distal and proximal length of the inlet)
c. The circumference of the inlet.
30. The change in the shape of the fetal skull produced by the force of uterine contractions pressing
the vertex of the head against the not-yet-dilated cervix is referred to as?
a. Attitude
b. Effacement
c. Molding
d. Engagement

III. Using the GTPALM method, assess & document the obstetrical history of the following clients:

31. A 32 years old female who is currently on its 22 weeks AOG, prior to her current pregnancy she
had a still birth at 32 weeks AOG and a miscarriage at 18 weeks AOG. She has one daughter who
is 18 years old now and was born at 36 weeks AOG.
G T P A L M

32. Mrs. XYZ, a 40 years old female, with history of recurrent pregnancy loss due to antiphospholipid
antibodies (APA), She is currently on her 32 weeks AOG, she had already lost three pregnancies,
one at 32 weeks AOG, one at 24 weeks AOG and her last was at 18 weeks AOG.
G T P A L M

33. Ms. PW who is at her 36 weeks AOG, her first pregnancy was a twin delivered at 38 weeks AOG,
prior to her twins, she had given birth to a 24-week stillbirth and two succeeding molar
pregnancies prior to her current pregnancy.
G T P A L M

34. Ms. QRS a 28 years old female, who had suffered her 3rd miscarriage at 18 weeks AOG. Her
previous pregnancy, a male, now 10 years of age, full-term and a baby girl, 4 years old, who was
born at 36 weeks AOG.
G T P A L M

35. Mrs. LVM who had recently delivered at 18 week AOG, prior to this she had a childbirth at 36
weeks AOG and another at 38 weeks AOG. Her very first pregnancy at age 20 years was a molar
pregnancy, thus, it was surgically removed. She had one living son who is now 15 years old.
G T P A L M

IV. Clinical Scenario 2: Case Analysis

Patient X, on her 27 weeks of AOG, G1 P0, came in the OB-Emergency Care Unit due to frequent and
intense labor pains, lasting 40 to 60 seconds, and occur approximately every 3 to 5 minutes. She also
verbalized possible ruptured bag of water, which she described as a sudden gush of clear liquid. She was
accompanied by her partner. The couple are both worried because the patient’s EDC was supposedly in
two weeks from that day. Vital signs were taken and as follows: BP-180/100, RR-22, CR-100, Temp-37
degrees Celsius. The patient was admitted at the labor room to be assessed by her Obstetrician; for
possible delivery.

36. Based on the characteristics of the labor pains, as a nurse you would know that the patient is in
what stage of labor?

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 a. First
b. Second
c. Third
37. As a nullipara, you should explain that this phase of labor will most probably last for how long?
a. Most probably 3 hours
b. Most probably 4 hours
c. Most probably 8 hours
d. May vary depending on the age of the patient but usually 4 hours
38. During this phase, what advise could you give the patient in terms of activity?
a. Remain well rested and avoid unnecessary movement including withholding of bathroom
privileges. Assure the patient that you are willing to assist her in any activity she wished
to do.
b. Encourage the patient to remain active participants in labor by assuming what position is
most comfortable for them during this time.
c. Encourage the patient to not be afraid or anxious about the whole experience. Assure her
that she and her unborn child will be monitored closely until the time the baby is
delivered. Encourage the patient’s partner to be active participant throughout the entire
phase of labor and delivery.
39. At this stage and phase of labor, the patient asks you if the labor pain will increase more; if she
will suffer more because of it. Your best response should be:
a. Tell the patient that this phase of labor can be a difficult time for a woman because
contractions grow strong, last longer, and begin to cause true discomfort. However, the
patient and the unborn child will be closely monitored.
b. Tell the patient that as she reaches the end of this stage a new sensation such an irresistible
urge to push occurs. Assure the patient that this is normal and this is already a sign that
the pregnancy is nearing the end.
c. Tell the patient that she will feel contraction changes from the characteristic crescendo–
decrescendo pattern to an overwhelming, uncontrollable urge to push or bear down with
each contraction as if to move her bowels. Assure her that this is a normal part of this
phase of labor.
40. After several hours, the patient reported an increase intensity in contractions, occurring every 2
to 3 minutes with duration of 60 to 90 seconds. Upon internal examination of the cervix,
maximum cervical dilatation of 8 to 10 cm is noted by the OB residents. This is a sign that the labor
is already at what phase?
a. Latent
b. Active
c. Transition
41. The stage of labor which is the period from full dilatation and cervical effacement to birth of the
infant.
a. First
b. Second
c. Third
42. The following signs indicate that the placenta has loosened and is ready to deliver, EXCEPT:
a. Change in the shape of the uterus, instable contraction of the uterus, appearance of the
maternal side of placenta at the vaginal opening.
b. Lengthening of the umbilical cord, sudden gush of vaginal blood, change in the shape of
the uterus.
c. Lengthening of the umbilical cord, sudden gush of a pinkish liquid, change in the shape of
the uterus, appearance of the shiny part of the placenta.
43. The cardinal movement of labor that is characterized by the downward movement of the
biparietal diameter of the fetal head to within the pelvic inlet.
a. Engagement
b. Effacement
c. Descent
d. Expulsion
44. A type of fetal presentation that occurs in approximately 3% of births and are affected by fetal
attitude.
a. Cephalic
b. Breech
c. Shoulder
45. The relationship of the presenting part of the fetus to a specific quadrant of a woman’s pelvis, is
referred to as:
a. Presentation
b. Descent

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 c. Position
46. The relationship between the long (cephalocaudal) axis of the fetal body and the long
(cephalocaudal) axis of a woman’s body, is referred to as:
a. Fetal Lie
b. Fetal Postion
c. Fetal Presentation
47. This refers to the relationship of the presenting part of a fetus to the level of the ischial spines.
a. Engagement
b. Fetal Lie
c. Station
48. Placental presentation that is characterized by a shiny and glistening appearance of the placenta
(from the fetal membranes).
a. Schultze
b. Duncan
c. Chadwick
49. Approximately 80% of placentas separate and present in this way.
a. Schultze
b. Duncan
c. Chadwick
50. Which statement BEST describes Placental Expulsion?
a. After separation, the placenta is delivered either by the natural bearing-down effort of the
mother or by vigorous yanking on the attached umbilical cord on the contracted uterine
fundus by a physician or nurse/ midwife (Credé’s maneuver).
b. Pressure must never be applied to a uterus in a non-contracted state, because doing so
may cause the uterus to evert and hemorrhage.
c. If the placenta does not deliver spontaneously, it can be removed manually through
dilatation and curettage, which will require the mother to be sedated.

“The path from dreams to success does exist. May you have the vision to find it, the courage to get on
to it, and the perseverance to follow it.” -- Kalpana Chawla
Good Luck!

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