NR327/NR 327 Exam 3 V2 | Maternal Child
Nursing Q&A with Rationale | Chamberlain
University
1. A nurse is assessing a newborn 1 minute after birth and observes the following: heart rate
110 bpm, slow/irregular respiratory effort, some flexion of extremities, grimace in response
to suctioning, and a pink body with blue extremities. What APGAR score should the nurse
assign?
A. 5
B. 8
C. 7
D. 6
Correct Answer: D
Rationale: The newborn receives 2 points for heart rate over 100, 1 point for slow
respiration, 1 point for some flexion, 1 point for grimace, and 1 point for acrocyanosis. This
totals a score of 6, indicating moderate distress requiring intervention. The APGAR
assessment is standardized to determine the immediate need for neonatal resuscitation.
2. Which developmental milestone is expected for a 4-month-old infant according to standard
growth and development charts?
A. Sitting alone without support
,B. Using a pincer grasp
C. Rolling from back to side
D. Creeping on hands and knees
Correct Answer: C
Rationale: By 4 months, infants typically begin rolling from back to side and can lift their
head and chest 90 degrees when prone. Sitting without support usually occurs around 6 to
8 months. The pincer grasp and creeping are milestones associated with late infancy,
specifically between 8 to 10 months.
3. A toddler is admitted with suspected Laryngotracheobronchitis (Croup). Which clinical
manifestation should the nurse anticipate?
A. Drooling and high fever
B. Barky, brassy cough
C. Expiratory wheezing
D. Productive cough with thick sputum
Correct Answer: B
Rationale: Croup is characterized by subglottic inflammation that produces a distinctive
bark-like cough and inspiratory stridor. Drooling and high fever are more indicative of
epiglottitis, which is a medical emergency. Expiratory wheezing is common in bronchiolitis
or asthma rather than croup.
, 4. A nurse is caring for a school-age child with Cystic Fibrosis. What is a priority nursing
intervention for respiratory management?
A. Administering cough suppressants before bed
B. Limiting fluid intake to prevent pulmonary edema
C. Performing chest physiotherapy (CPT) twice daily
D. Placing the child in a supine position
Correct Answer: C
Rationale: Chest physiotherapy is vital to clear thick, tenacious mucus from the airways in
patients with Cystic Fibrosis. Cough suppressants should be avoided because the goal is to
expectorate secretions to prevent infection. High fluid intake is actually encouraged to help
thin the mucus for easier clearance.
5. In a child diagnosed with Tetralogy of Fallot, what should the nurse do first when the child
experiences a ‘Tet spell’?
A. Place the child in the knee-chest position
B. Administer 100% oxygen via face mask
C. Prepare for immediate administration of Morphine
D. Call for the Rapid Response Team
Correct Answer: A
Nursing Q&A with Rationale | Chamberlain
University
1. A nurse is assessing a newborn 1 minute after birth and observes the following: heart rate
110 bpm, slow/irregular respiratory effort, some flexion of extremities, grimace in response
to suctioning, and a pink body with blue extremities. What APGAR score should the nurse
assign?
A. 5
B. 8
C. 7
D. 6
Correct Answer: D
Rationale: The newborn receives 2 points for heart rate over 100, 1 point for slow
respiration, 1 point for some flexion, 1 point for grimace, and 1 point for acrocyanosis. This
totals a score of 6, indicating moderate distress requiring intervention. The APGAR
assessment is standardized to determine the immediate need for neonatal resuscitation.
2. Which developmental milestone is expected for a 4-month-old infant according to standard
growth and development charts?
A. Sitting alone without support
,B. Using a pincer grasp
C. Rolling from back to side
D. Creeping on hands and knees
Correct Answer: C
Rationale: By 4 months, infants typically begin rolling from back to side and can lift their
head and chest 90 degrees when prone. Sitting without support usually occurs around 6 to
8 months. The pincer grasp and creeping are milestones associated with late infancy,
specifically between 8 to 10 months.
3. A toddler is admitted with suspected Laryngotracheobronchitis (Croup). Which clinical
manifestation should the nurse anticipate?
A. Drooling and high fever
B. Barky, brassy cough
C. Expiratory wheezing
D. Productive cough with thick sputum
Correct Answer: B
Rationale: Croup is characterized by subglottic inflammation that produces a distinctive
bark-like cough and inspiratory stridor. Drooling and high fever are more indicative of
epiglottitis, which is a medical emergency. Expiratory wheezing is common in bronchiolitis
or asthma rather than croup.
, 4. A nurse is caring for a school-age child with Cystic Fibrosis. What is a priority nursing
intervention for respiratory management?
A. Administering cough suppressants before bed
B. Limiting fluid intake to prevent pulmonary edema
C. Performing chest physiotherapy (CPT) twice daily
D. Placing the child in a supine position
Correct Answer: C
Rationale: Chest physiotherapy is vital to clear thick, tenacious mucus from the airways in
patients with Cystic Fibrosis. Cough suppressants should be avoided because the goal is to
expectorate secretions to prevent infection. High fluid intake is actually encouraged to help
thin the mucus for easier clearance.
5. In a child diagnosed with Tetralogy of Fallot, what should the nurse do first when the child
experiences a ‘Tet spell’?
A. Place the child in the knee-chest position
B. Administer 100% oxygen via face mask
C. Prepare for immediate administration of Morphine
D. Call for the Rapid Response Team
Correct Answer: A
