NUR 230 Final Exam V2 | NUR 230 The
Childbearing / Child Caring Family | Q&A
with Rationale (NUR230 Final Exam) |
Galen College of Nursing
1. A nurse is caring for a client who is at 34 weeks of gestation and has a prescription for
magnesium sulfate IV to treat preeclampsia. Which of the following findings should the nurse
report to the provider as an indication of magnesium toxicity?
A. Deep tendon reflexes 2+
B. Respiratory rate 10/min
C. Urinary output 40 mL/hr
D. Serum magnesium level 6 mEq/L
Answer: B
Rationale: Magnesium sulfate is a central nervous system depressant used to prevent
seizures in preeclampsia. A respiratory rate below 12/min is a primary indicator of
magnesium toxicity and requires immediate cessation of the infusion. The nurse must also
monitor for the loss of deep tendon reflexes and a significant drop in urinary output below
30 mL/hr.
2. A nurse is assessing a newborn 1 hour after birth. Which of the following respiratory rates
is within the expected reference range for a newborn?
A. 20 to 40/min
,B. 30 to 60/min
C. 40 to 80/min
D. 60 to 100/min
Answer: B
Rationale: The normal respiratory rate for a newborn typically ranges from 30 to 60
breaths per minute. These respirations are often irregular, diaphragmatic, and shallow in
nature. Any rate consistently outside this range or signs of nasal flaring and grunting
should be investigated for respiratory distress.
3. A nurse is providing teaching to a parent of a child who has cystic fibrosis and a
prescription for pancreatic enzymes. When should the nurse instruct the parent to administer
the enzymes?
A. Once daily in the morning
B. Three times a day after meals
C. Only when the child has a fatty stool
D. With every meal and snack
Answer: D
Rationale: Children with cystic fibrosis require pancreatic enzyme replacement therapy to
assist with the digestion and absorption of fats and proteins. These enzymes must be taken
, with every meal and snack to ensure they are present in the intestines when food arrives.
Failure to adhere to this schedule leads to malabsorption and characteristic steatorrhea.
4. A nurse is caring for a client who is in the first stage of labor and observes late
decelerations on the fetal monitor strip. Which of the following actions should the nurse take
first?
A. Administer oxygen via nonrebreather mask
B. Increase the rate of the IV fluid infusion
C. Assist the client into a side-lying position
D. Notify the provider of the monitor pattern
Answer: C
Rationale: Late decelerations indicate uteroplacental insufficiency, which is a critical
threat to fetal oxygenation. Repositioning the client to a side-lying position is the priority
action to improve blood flow to the placenta by relieving pressure on the vena cava.
Following this, the nurse should increase fluids, apply oxygen, and then notify the
healthcare provider.
5. Which of the following is an expected finding for a toddler who has a diagnosis of
intussusception?
A. Constant abdominal rigidity
B. Projectile vomiting
C. Ribbon-like stools
Childbearing / Child Caring Family | Q&A
with Rationale (NUR230 Final Exam) |
Galen College of Nursing
1. A nurse is caring for a client who is at 34 weeks of gestation and has a prescription for
magnesium sulfate IV to treat preeclampsia. Which of the following findings should the nurse
report to the provider as an indication of magnesium toxicity?
A. Deep tendon reflexes 2+
B. Respiratory rate 10/min
C. Urinary output 40 mL/hr
D. Serum magnesium level 6 mEq/L
Answer: B
Rationale: Magnesium sulfate is a central nervous system depressant used to prevent
seizures in preeclampsia. A respiratory rate below 12/min is a primary indicator of
magnesium toxicity and requires immediate cessation of the infusion. The nurse must also
monitor for the loss of deep tendon reflexes and a significant drop in urinary output below
30 mL/hr.
2. A nurse is assessing a newborn 1 hour after birth. Which of the following respiratory rates
is within the expected reference range for a newborn?
A. 20 to 40/min
,B. 30 to 60/min
C. 40 to 80/min
D. 60 to 100/min
Answer: B
Rationale: The normal respiratory rate for a newborn typically ranges from 30 to 60
breaths per minute. These respirations are often irregular, diaphragmatic, and shallow in
nature. Any rate consistently outside this range or signs of nasal flaring and grunting
should be investigated for respiratory distress.
3. A nurse is providing teaching to a parent of a child who has cystic fibrosis and a
prescription for pancreatic enzymes. When should the nurse instruct the parent to administer
the enzymes?
A. Once daily in the morning
B. Three times a day after meals
C. Only when the child has a fatty stool
D. With every meal and snack
Answer: D
Rationale: Children with cystic fibrosis require pancreatic enzyme replacement therapy to
assist with the digestion and absorption of fats and proteins. These enzymes must be taken
, with every meal and snack to ensure they are present in the intestines when food arrives.
Failure to adhere to this schedule leads to malabsorption and characteristic steatorrhea.
4. A nurse is caring for a client who is in the first stage of labor and observes late
decelerations on the fetal monitor strip. Which of the following actions should the nurse take
first?
A. Administer oxygen via nonrebreather mask
B. Increase the rate of the IV fluid infusion
C. Assist the client into a side-lying position
D. Notify the provider of the monitor pattern
Answer: C
Rationale: Late decelerations indicate uteroplacental insufficiency, which is a critical
threat to fetal oxygenation. Repositioning the client to a side-lying position is the priority
action to improve blood flow to the placenta by relieving pressure on the vena cava.
Following this, the nurse should increase fluids, apply oxygen, and then notify the
healthcare provider.
5. Which of the following is an expected finding for a toddler who has a diagnosis of
intussusception?
A. Constant abdominal rigidity
B. Projectile vomiting
C. Ribbon-like stools
