NUR 418 / NUR 415 Exam 2 V3 | NUR 418 /
NUR 415 Nursing Care of the Childbearing
& Childrearing Family | Actual Q&A with
Rationale (NUR418/NUR415 Exam 2) |
Concordia
1. A nurse is assessing a client at 34 weeks of gestation who has a diagnosis of severe
preeclampsia. Which of the following findings should the nurse report to the provider
immediately? (Select all that apply.)
A. Epigastric pain
B. Blurred vision
C. 1+ pedal edema
D. Urinary output of 20 mL/hr
E. Platelet count of 150,000/mm3
F. Severe headache
Correct Answer: A, B, D, F
Explanation; Severe preeclampsia involves multi-system failure and CNS irritability.
Epigastric pain indicates hepatic involvement, while blurred vision and headache are signs
of cerebral edema. Oliguria (less than 30 mL/hr) indicates compromised renal perfusion
and requires immediate intervention to prevent eclampsia.
,2. A nurse is caring for a client receiving magnesium sulfate IV for preeclampsia. Which of the
following findings indicates magnesium toxicity?
A. Blood pressure 150/90 mmHg
B. Presence of deep tendon reflexes
C. Urinary output 40 mL/hr
D. Respiratory rate 10/min
Correct Answer: D
Explanation; A respiratory rate of less than 12/min is a primary sign of magnesium sulfate
toxicity. The nurse should also monitor for the loss of deep tendon reflexes and a significant
drop in urinary output. Calcium gluconate is the standard antidote that should be kept at
the bedside.
3. 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 medication with orange juice.
B. Take the medication with a glass of milk.
C. Expect stools to become light clay-colored.
D. Administer the medication at bedtime to avoid nausea.
Correct Answer: A
, Explanation; Vitamin C, found in orange juice, enhances the absorption of iron. Milk and
antacids should be avoided as they interfere with absorption. It is also important to warn
the client that iron supplements can cause dark, green, or black stools.
4. A nurse is reviewing the electronic fetal heart rate (FHR) tracing of a client in labor. The
nurse notes late decelerations. Which of the following actions should the nurse take first?
A. Administer oxygen at 8 to 10 L/min via nonrebreather mask.
B. Assist the client into a lateral position.
C. Increase the IV fluid infusion rate.
D. Notify the provider.
Correct Answer: B
Explanation; Late decelerations indicate uteroplacental insufficiency. The first priority is
to improve placental perfusion by repositioning the client to a side-lying (lateral) position.
Following this, oxygen administration and increasing IV fluids are appropriate secondary
interventions.
5. A nurse is caring for an infant who has developmental dysplasia of the hip (DDH). Which of
the following clinical manifestations should the nurse expect?
A. Lengthening of the limb on the affected side
B. Symmetrical gluteal folds
C. Positive Ortolani test
NUR 415 Nursing Care of the Childbearing
& Childrearing Family | Actual Q&A with
Rationale (NUR418/NUR415 Exam 2) |
Concordia
1. A nurse is assessing a client at 34 weeks of gestation who has a diagnosis of severe
preeclampsia. Which of the following findings should the nurse report to the provider
immediately? (Select all that apply.)
A. Epigastric pain
B. Blurred vision
C. 1+ pedal edema
D. Urinary output of 20 mL/hr
E. Platelet count of 150,000/mm3
F. Severe headache
Correct Answer: A, B, D, F
Explanation; Severe preeclampsia involves multi-system failure and CNS irritability.
Epigastric pain indicates hepatic involvement, while blurred vision and headache are signs
of cerebral edema. Oliguria (less than 30 mL/hr) indicates compromised renal perfusion
and requires immediate intervention to prevent eclampsia.
,2. A nurse is caring for a client receiving magnesium sulfate IV for preeclampsia. Which of the
following findings indicates magnesium toxicity?
A. Blood pressure 150/90 mmHg
B. Presence of deep tendon reflexes
C. Urinary output 40 mL/hr
D. Respiratory rate 10/min
Correct Answer: D
Explanation; A respiratory rate of less than 12/min is a primary sign of magnesium sulfate
toxicity. The nurse should also monitor for the loss of deep tendon reflexes and a significant
drop in urinary output. Calcium gluconate is the standard antidote that should be kept at
the bedside.
3. 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 medication with orange juice.
B. Take the medication with a glass of milk.
C. Expect stools to become light clay-colored.
D. Administer the medication at bedtime to avoid nausea.
Correct Answer: A
, Explanation; Vitamin C, found in orange juice, enhances the absorption of iron. Milk and
antacids should be avoided as they interfere with absorption. It is also important to warn
the client that iron supplements can cause dark, green, or black stools.
4. A nurse is reviewing the electronic fetal heart rate (FHR) tracing of a client in labor. The
nurse notes late decelerations. Which of the following actions should the nurse take first?
A. Administer oxygen at 8 to 10 L/min via nonrebreather mask.
B. Assist the client into a lateral position.
C. Increase the IV fluid infusion rate.
D. Notify the provider.
Correct Answer: B
Explanation; Late decelerations indicate uteroplacental insufficiency. The first priority is
to improve placental perfusion by repositioning the client to a side-lying (lateral) position.
Following this, oxygen administration and increasing IV fluids are appropriate secondary
interventions.
5. A nurse is caring for an infant who has developmental dysplasia of the hip (DDH). Which of
the following clinical manifestations should the nurse expect?
A. Lengthening of the limb on the affected side
B. Symmetrical gluteal folds
C. Positive Ortolani test
