NUR166/NUR 166 Final Exam V1 |
Concepts of Family Centered Nursing for
the Practical Nurse Q&A with Rationale |
Hondros College of Nursing
1. A nurse is caring for a client in the first stage of labor and notices late decelerations on the
fetal heart rate monitor. What is the priority nursing action?
A. Assist the client to a side-lying position.
B. Increase the IV oxytocin infusion rate.
C. Prepare the client for an immediate amniotomy.
D. Administer 2L of oxygen via nasal cannula.
Correct Answer: A
Rationale: Late decelerations indicate uteroplacental insufficiency, which is a critical
concern for fetal oxygenation. Repositioning the mother to a side-lying position helps
improve blood flow to the placenta by relieving pressure on the inferior vena cava. This
intervention is the first step in intrauterine resuscitation followed by oxygen and IV fluids.
2. Which developmental task should a nurse expect a 2-year-old toddler to be working on
according to Erikson’s stages of psychosocial development?
A. Trust vs. Mistrust
B. Initiative vs. Guilt
,C. Autonomy vs. Shame and Doubt
D. Industry vs. Inferiority
Correct Answer: C
Rationale: Toddlers between the ages of 1 and 3 years are in the stage of Autonomy
vs. Shame and Doubt. During this period, children strive for independence and control over
their environment and bodily functions. Successful completion of this stage leads to self-
confidence and a sense of adequacy.
3. A postpartum nurse is assessing a client 4 hours after delivery and finds the fundus is boggy
and displaced to the right. What is the most likely cause?
A. Uterine atony from a large infant
B. Endometritis
C. Retained placental fragments
D. A full bladder
Correct Answer: D
Rationale: A fundus that is displaced from the midline, typically to the right, is a classic
sign of bladder distention. A full bladder prevents the uterus from contracting effectively,
which can lead to increased bleeding. The nurse should encourage the client to void or
perform catheterization if necessary.
, 4. A nurse is providing discharge teaching to a mother of a newborn regarding SIDS
prevention. Which statement by the mother indicates an understanding of the teaching?
A. ‘I will place my baby on their stomach to sleep so they don’t choke.’
B. ‘I will put soft blankets and pillows in the crib to keep the baby warm.’
C. ‘I will keep the room temperature very warm to prevent the baby from getting a cold.’
D. ‘I will place my baby on their back to sleep on a firm mattress.’
Correct Answer: D
Rationale: The ‘Back to Sleep’ campaign recommends placing infants on their backs to
reduce the risk of Sudden Infant Death Syndrome (SIDS). Using a firm sleep surface and
avoiding soft bedding or toys in the crib are also essential safety measures. These practices
significantly decrease the incidence of accidental suffocation or overheating.
5. When assessing a newborn, the nurse notes small white sebaceous glands on the bridge of
the nose and chin. How should the nurse document this finding?
A. Lanugo
B. Vernix caseosa
C. Milia
D. Mongolian spots
Correct Answer: C
Concepts of Family Centered Nursing for
the Practical Nurse Q&A with Rationale |
Hondros College of Nursing
1. A nurse is caring for a client in the first stage of labor and notices late decelerations on the
fetal heart rate monitor. What is the priority nursing action?
A. Assist the client to a side-lying position.
B. Increase the IV oxytocin infusion rate.
C. Prepare the client for an immediate amniotomy.
D. Administer 2L of oxygen via nasal cannula.
Correct Answer: A
Rationale: Late decelerations indicate uteroplacental insufficiency, which is a critical
concern for fetal oxygenation. Repositioning the mother to a side-lying position helps
improve blood flow to the placenta by relieving pressure on the inferior vena cava. This
intervention is the first step in intrauterine resuscitation followed by oxygen and IV fluids.
2. Which developmental task should a nurse expect a 2-year-old toddler to be working on
according to Erikson’s stages of psychosocial development?
A. Trust vs. Mistrust
B. Initiative vs. Guilt
,C. Autonomy vs. Shame and Doubt
D. Industry vs. Inferiority
Correct Answer: C
Rationale: Toddlers between the ages of 1 and 3 years are in the stage of Autonomy
vs. Shame and Doubt. During this period, children strive for independence and control over
their environment and bodily functions. Successful completion of this stage leads to self-
confidence and a sense of adequacy.
3. A postpartum nurse is assessing a client 4 hours after delivery and finds the fundus is boggy
and displaced to the right. What is the most likely cause?
A. Uterine atony from a large infant
B. Endometritis
C. Retained placental fragments
D. A full bladder
Correct Answer: D
Rationale: A fundus that is displaced from the midline, typically to the right, is a classic
sign of bladder distention. A full bladder prevents the uterus from contracting effectively,
which can lead to increased bleeding. The nurse should encourage the client to void or
perform catheterization if necessary.
, 4. A nurse is providing discharge teaching to a mother of a newborn regarding SIDS
prevention. Which statement by the mother indicates an understanding of the teaching?
A. ‘I will place my baby on their stomach to sleep so they don’t choke.’
B. ‘I will put soft blankets and pillows in the crib to keep the baby warm.’
C. ‘I will keep the room temperature very warm to prevent the baby from getting a cold.’
D. ‘I will place my baby on their back to sleep on a firm mattress.’
Correct Answer: D
Rationale: The ‘Back to Sleep’ campaign recommends placing infants on their backs to
reduce the risk of Sudden Infant Death Syndrome (SIDS). Using a firm sleep surface and
avoiding soft bedding or toys in the crib are also essential safety measures. These practices
significantly decrease the incidence of accidental suffocation or overheating.
5. When assessing a newborn, the nurse notes small white sebaceous glands on the bridge of
the nose and chin. How should the nurse document this finding?
A. Lanugo
B. Vernix caseosa
C. Milia
D. Mongolian spots
Correct Answer: C
