NUR 230 Final Exam V3 | 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 in the first stage of labor and has an internal fetal
monitor. The nurse notes a pattern of late decelerations on the fetal heart rate monitor.
Which of the following actions should the nurse take first?
A. Increase the rate of the IV fluid infusion.
B. Assist the client into a side-lying position.
C. Apply oxygen at 10 L/min via nonrebreather mask.
D. Prepare for an immediate vaginal examination.
Answer: B
Rationale: Late decelerations are caused by uteroplacental insufficiency and indicate fetal
distress. The first action the nurse should take is to position the client on her side to
increase blood flow to the placenta and the fetus. This intervention is non-invasive and
addresses the physiological cause of the deceleration immediately.
,2. A nurse is assessing a 4-year-old child during a routine wellness visit. According to Erikson’s
stages of psychosocial development, which of the following developmental tasks should the
nurse expect the child to be working on?
A. Autonomy vs. Shame and Doubt
B. Industry vs. Inferiority
C. Trust vs. Mistrust
D. Initiative vs. Guilt
Answer: D
Rationale: According to Erikson, preschoolers (ages 3 to 6 years) are in the stage of
Initiative vs. Guilt. During this stage, children begin to assert control and power over their
environment by planning activities and making up games. If this tendency is squelched
through criticism or control, children develop a sense of guilt.
3. A nurse is providing discharge teaching to the parents of a child who has cystic fibrosis.
Which of the following instructions should the nurse include regarding the administration of
pancreatic enzymes?
A. Administer the enzymes twice daily with breakfast and dinner.
B. Give the enzymes 30 minutes after each meal and snack.
C. Administer the enzymes with every meal and snack the child consumes.
D. Skip the dose if the child is having a loose, fatty stool.
,Answer: C
Rationale: Children with cystic fibrosis require pancreatic enzymes to assist with the
digestion and absorption of fats, proteins, and carbohydrates. These enzymes must be
taken with every meal and snack to be effective. Failure to provide enzymes with food
results in malabsorption and steatorrhea.
4. A nurse is assessing a client who is 2 hours postpartum and has a boggy fundus that is
displaced to the right. Which of the following actions should the nurse take?
A. Administer oxytocin as prescribed.
B. Massage the fundus until it is firm.
C. Assist the client to the bathroom to void.
D. Check the client’s blood pressure.
Answer: C
Rationale: A fundus that is displaced to the right and is boggy usually indicates a distended
bladder. A full bladder prevents the uterus from contracting effectively, which increases the
risk of postpartum hemorrhage. Assisting the client to void is the priority intervention to
allow the uterus to return to the midline and contract.
5. A nurse is caring for a 6-month-old infant who has been admitted with acute
gastroenteritis. Which of the following findings should the nurse identify as a priority to
report to the provider?
A. Three episodes of watery diarrhea in 8 hours.
, B. Dry mucous membranes and decreased tearing.
C. Irritability when being held by the nurse.
D. A capillary refill time of greater than 4 seconds.
Answer: D
Rationale: A capillary refill time greater than 4 seconds is a sign of severe dehydration and
compromised peripheral perfusion in an infant. This finding indicates a medical emergency
that requires immediate fluid resuscitation. While diarrhea and dry membranes are
concerning, circulatory collapse is the highest priority.
6. A nurse is providing teaching to a client who is at 12 weeks of gestation and has a new
prescription for an iron supplement. Which of the following instructions should the nurse
include?
A. Take the supplement with orange juice.
B. Take the supplement with a glass of milk.
C. Expect stools to become light green in color.
D. Take the supplement immediately before going to sleep.
Answer: A
Rationale: Vitamin C, found in orange juice, significantly enhances the absorption of iron.
Milk and calcium-containing products should be avoided at the same time as iron because
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 in the first stage of labor and has an internal fetal
monitor. The nurse notes a pattern of late decelerations on the fetal heart rate monitor.
Which of the following actions should the nurse take first?
A. Increase the rate of the IV fluid infusion.
B. Assist the client into a side-lying position.
C. Apply oxygen at 10 L/min via nonrebreather mask.
D. Prepare for an immediate vaginal examination.
Answer: B
Rationale: Late decelerations are caused by uteroplacental insufficiency and indicate fetal
distress. The first action the nurse should take is to position the client on her side to
increase blood flow to the placenta and the fetus. This intervention is non-invasive and
addresses the physiological cause of the deceleration immediately.
,2. A nurse is assessing a 4-year-old child during a routine wellness visit. According to Erikson’s
stages of psychosocial development, which of the following developmental tasks should the
nurse expect the child to be working on?
A. Autonomy vs. Shame and Doubt
B. Industry vs. Inferiority
C. Trust vs. Mistrust
D. Initiative vs. Guilt
Answer: D
Rationale: According to Erikson, preschoolers (ages 3 to 6 years) are in the stage of
Initiative vs. Guilt. During this stage, children begin to assert control and power over their
environment by planning activities and making up games. If this tendency is squelched
through criticism or control, children develop a sense of guilt.
3. A nurse is providing discharge teaching to the parents of a child who has cystic fibrosis.
Which of the following instructions should the nurse include regarding the administration of
pancreatic enzymes?
A. Administer the enzymes twice daily with breakfast and dinner.
B. Give the enzymes 30 minutes after each meal and snack.
C. Administer the enzymes with every meal and snack the child consumes.
D. Skip the dose if the child is having a loose, fatty stool.
,Answer: C
Rationale: Children with cystic fibrosis require pancreatic enzymes to assist with the
digestion and absorption of fats, proteins, and carbohydrates. These enzymes must be
taken with every meal and snack to be effective. Failure to provide enzymes with food
results in malabsorption and steatorrhea.
4. A nurse is assessing a client who is 2 hours postpartum and has a boggy fundus that is
displaced to the right. Which of the following actions should the nurse take?
A. Administer oxytocin as prescribed.
B. Massage the fundus until it is firm.
C. Assist the client to the bathroom to void.
D. Check the client’s blood pressure.
Answer: C
Rationale: A fundus that is displaced to the right and is boggy usually indicates a distended
bladder. A full bladder prevents the uterus from contracting effectively, which increases the
risk of postpartum hemorrhage. Assisting the client to void is the priority intervention to
allow the uterus to return to the midline and contract.
5. A nurse is caring for a 6-month-old infant who has been admitted with acute
gastroenteritis. Which of the following findings should the nurse identify as a priority to
report to the provider?
A. Three episodes of watery diarrhea in 8 hours.
, B. Dry mucous membranes and decreased tearing.
C. Irritability when being held by the nurse.
D. A capillary refill time of greater than 4 seconds.
Answer: D
Rationale: A capillary refill time greater than 4 seconds is a sign of severe dehydration and
compromised peripheral perfusion in an infant. This finding indicates a medical emergency
that requires immediate fluid resuscitation. While diarrhea and dry membranes are
concerning, circulatory collapse is the highest priority.
6. A nurse is providing teaching to a client who is at 12 weeks of gestation and has a new
prescription for an iron supplement. Which of the following instructions should the nurse
include?
A. Take the supplement with orange juice.
B. Take the supplement with a glass of milk.
C. Expect stools to become light green in color.
D. Take the supplement immediately before going to sleep.
Answer: A
Rationale: Vitamin C, found in orange juice, significantly enhances the absorption of iron.
Milk and calcium-containing products should be avoided at the same time as iron because
