NUR 3300 Exam 3 V3 | NUR 3300 Nursing
Practice II | Q&A with Rationale (NUR3300
Exam 3) | William Paterson University
1. A nurse is caring for a client in the active phase of labor who is receiving oxytocin. The
nurse notes late decelerations on the fetal heart rate monitor. What is the priority nursing
action?
A. Increase the oxytocin infusion rate.
B. Document the findings as a normal physiological response.
C. Administer oxygen via a simple face mask at 2 L/min.
D. Reposition the client to a side-lying position.
Answer: D
Rationale: Late decelerations are indicative of uteroplacental insufficiency, which requires
immediate intervention to improve fetal oxygenation. Repositioning the client to the lateral
side-lying position helps alleviate pressure on the vena cava and improves blood flow to
the placenta. The nurse must also discontinue the oxytocin infusion and increase IV fluids
as part of the intrauterine resuscitation protocol.
2. A 4-year-old child is admitted to the pediatric unit with suspected acute epiglottitis. Which
of the following provider orders should the nurse question?
A. Obtain a throat culture to identify the pathogen.
,B. Keep the child in an upright sitting position.
C. Administer IV antibiotics as ordered.
D. Monitor continuous pulse oximetry.
Answer: A
Rationale: Obtaining a throat culture is contraindicated in a child with suspected
epiglottitis because it can trigger a sudden airway spasm and complete obstruction. The
nurse should maintain a calm environment and avoid any invasive procedures that might
agitate the child. Emergency airway equipment, including an intubation kit, must be readily
available at the bedside at all times.
3. A postpartum client who delivered 2 hours ago is experiencing heavy vaginal bleeding and
a boggy uterus. Which medication does the nurse anticipate the provider will order first?
A. Terbutaline
B. Betamethasone
C. Magnesium Sulfate
D. Oxytocin
Answer: D
Rationale: Oxytocin is the first-line medication used to stimulate uterine contractions and
manage postpartum hemorrhage caused by uterine atony. A boggy uterus indicates that the
muscle fibers are not contracting effectively to compress the blood vessels. The nurse
,should also perform fundal massage to help firm the uterus while preparing the medication
for administration.
4. A nurse is assessing a newborn 1 minute after birth. The newborn has a heart rate of 110
bpm, a weak cry, some flexion of extremities, is grimacing, and has a pink body with blue
extremities. What is the Apgar score?
A. 5
B. 7
C. 6
D. 8
Answer: C
Rationale: The score is calculated as follows: Heart rate >100 (2 points), weak cry/slow
respirations (1 point), some flexion (1 point), grimace (1 point), and acrocyanosis/pink
body with blue extremities (1 point). This totals 6, which indicates the newborn is having
some difficulty adjusting to extrauterine life. Scores between 4 and 6 usually require
immediate intervention such as suctioning or oxygen administration.
5. Which developmental milestone is expected for a 12-month-old infant according to
Erikson’s stages of psychosocial development?
A. Developing a sense of Autonomy
B. Developing a sense of Trust
C. Developing a sense of Initiative
, D. Developing a sense of Industry
Answer: B
Rationale: According to Erikson, the primary task of infancy (birth to 1 year) is Trust
vs. Mistrust. The infant learns to trust that their basic needs for food, warmth, and comfort
will be met by the caregiver. Success in this stage leads to the virtue of hope, while failure
can lead to fear and a belief that the world is unpredictable.
6. A client with preeclampsia is receiving Magnesium Sulfate. Which assessment finding
should the nurse report to the provider immediately?
A. Deep tendon reflexes of 2+
B. Fetal heart rate of 140 bpm
C. Urine output of 40 mL/hour
D. Respiratory rate of 10 breaths per minute
Answer: D
Rationale: A respiratory rate of 10 breaths per minute is a sign of magnesium toxicity, as
the drug acts as a central nervous system depressant. Other signs of toxicity include loss of
deep tendon reflexes, decreased urine output, and altered mental status. The nurse must
stop the infusion and prepare the antidote, Calcium Gluconate, if toxicity is suspected.
7. A toddler is admitted with severe dehydration due to gastroenteritis. Which clinical
manifestation should the nurse expect to find?
A. Bulging fontanels
Practice II | Q&A with Rationale (NUR3300
Exam 3) | William Paterson University
1. A nurse is caring for a client in the active phase of labor who is receiving oxytocin. The
nurse notes late decelerations on the fetal heart rate monitor. What is the priority nursing
action?
A. Increase the oxytocin infusion rate.
B. Document the findings as a normal physiological response.
C. Administer oxygen via a simple face mask at 2 L/min.
D. Reposition the client to a side-lying position.
Answer: D
Rationale: Late decelerations are indicative of uteroplacental insufficiency, which requires
immediate intervention to improve fetal oxygenation. Repositioning the client to the lateral
side-lying position helps alleviate pressure on the vena cava and improves blood flow to
the placenta. The nurse must also discontinue the oxytocin infusion and increase IV fluids
as part of the intrauterine resuscitation protocol.
2. A 4-year-old child is admitted to the pediatric unit with suspected acute epiglottitis. Which
of the following provider orders should the nurse question?
A. Obtain a throat culture to identify the pathogen.
,B. Keep the child in an upright sitting position.
C. Administer IV antibiotics as ordered.
D. Monitor continuous pulse oximetry.
Answer: A
Rationale: Obtaining a throat culture is contraindicated in a child with suspected
epiglottitis because it can trigger a sudden airway spasm and complete obstruction. The
nurse should maintain a calm environment and avoid any invasive procedures that might
agitate the child. Emergency airway equipment, including an intubation kit, must be readily
available at the bedside at all times.
3. A postpartum client who delivered 2 hours ago is experiencing heavy vaginal bleeding and
a boggy uterus. Which medication does the nurse anticipate the provider will order first?
A. Terbutaline
B. Betamethasone
C. Magnesium Sulfate
D. Oxytocin
Answer: D
Rationale: Oxytocin is the first-line medication used to stimulate uterine contractions and
manage postpartum hemorrhage caused by uterine atony. A boggy uterus indicates that the
muscle fibers are not contracting effectively to compress the blood vessels. The nurse
,should also perform fundal massage to help firm the uterus while preparing the medication
for administration.
4. A nurse is assessing a newborn 1 minute after birth. The newborn has a heart rate of 110
bpm, a weak cry, some flexion of extremities, is grimacing, and has a pink body with blue
extremities. What is the Apgar score?
A. 5
B. 7
C. 6
D. 8
Answer: C
Rationale: The score is calculated as follows: Heart rate >100 (2 points), weak cry/slow
respirations (1 point), some flexion (1 point), grimace (1 point), and acrocyanosis/pink
body with blue extremities (1 point). This totals 6, which indicates the newborn is having
some difficulty adjusting to extrauterine life. Scores between 4 and 6 usually require
immediate intervention such as suctioning or oxygen administration.
5. Which developmental milestone is expected for a 12-month-old infant according to
Erikson’s stages of psychosocial development?
A. Developing a sense of Autonomy
B. Developing a sense of Trust
C. Developing a sense of Initiative
, D. Developing a sense of Industry
Answer: B
Rationale: According to Erikson, the primary task of infancy (birth to 1 year) is Trust
vs. Mistrust. The infant learns to trust that their basic needs for food, warmth, and comfort
will be met by the caregiver. Success in this stage leads to the virtue of hope, while failure
can lead to fear and a belief that the world is unpredictable.
6. A client with preeclampsia is receiving Magnesium Sulfate. Which assessment finding
should the nurse report to the provider immediately?
A. Deep tendon reflexes of 2+
B. Fetal heart rate of 140 bpm
C. Urine output of 40 mL/hour
D. Respiratory rate of 10 breaths per minute
Answer: D
Rationale: A respiratory rate of 10 breaths per minute is a sign of magnesium toxicity, as
the drug acts as a central nervous system depressant. Other signs of toxicity include loss of
deep tendon reflexes, decreased urine output, and altered mental status. The nurse must
stop the infusion and prepare the antidote, Calcium Gluconate, if toxicity is suspected.
7. A toddler is admitted with severe dehydration due to gastroenteritis. Which clinical
manifestation should the nurse expect to find?
A. Bulging fontanels
