NUR 418 / NUR 415 Final Exam V2 | NUR
418 / NUR 415 Nursing Care of the
Childbearing & Childrearing Family |
Actual Q&A with Rationale
(NUR418/NUR415 Final Exam) | Concordia
1. A nurse is assessing a postpartum client 2 hours after delivery and notes that the fundus is
firm, midline, and at the level of the umbilicus, but there is heavy vaginal bleeding. Which of
the following actions should the nurse take first?
A. Massage the uterine fundus vigorously.
B. Check the client’s vital signs.
C. Notify the healthcare provider of potential cervical laceration.
D. Assess for a full bladder and encourage the client to void.
Correct Answer: C
Explanation; In a postpartum client with heavy bleeding and a firm, midline fundus, the
most likely cause of bleeding is a cervical or vaginal laceration rather than uterine atony.
Massaging a firm fundus is unnecessary and potentially harmful to the tissue. The nurse
should immediately notify the provider to assess for trauma that requires repair.
,2. A nurse is providing discharge instructions to a parent of an infant with a newly diagnosed
ventricular septal defect (VSD). Which statement by the parent indicates a need for further
teaching?
A. ‘I should expect my baby to be on a fluid restriction to prevent heart failure.’
B. ‘I will monitor my baby for rapid breathing and poor feeding.’
C. ‘We will need to keep our follow-up appointments with the cardiologist.’
D. ‘My baby might need extra calories added to their formula.’
Correct Answer: A
Explanation; Infants with VSD and significant shunting are at risk for heart failure, but
they are typically not placed on strict fluid restrictions because they require adequate
hydration and high caloric intake to support growth. Managing nutrition is a priority
because these infants often tire easily during feeding. Monitoring for respiratory distress
and following up with specialists are essential components of care.
3. Which of the following findings in a pregnant client at 34 weeks gestation should the nurse
report to the healthcare provider immediately?
A. Blurry vision and a persistent headache.
B. Leukorrhea and increased vaginal discharge.
C. Swelling of the ankles at the end of the day.
D. Backache that improves with rest.
,Correct Answer: A
Explanation; Blurry vision and persistent headaches are classic warning signs of
preeclampsia, which can progress to eclampsia or HELLP syndrome. While ankle edema is
common in late pregnancy, it is the systemic symptoms of hypertension that are most
concerning. Prompt evaluation of blood pressure and urine protein is required for safety.
4. Select All That Apply (SATA): A nurse is preparing to administer Magnesium Sulfate to a
client for seizure prophylaxis in preeclampsia. Which of the following assessments are
mandatory before and during administration?
A. Presence of deep tendon reflexes (DTRs)
B. Respiratory rate of at least 12 breaths per minute
C. Urine output of at least 30 mL/hr
D. Serum magnesium levels within therapeutic range
E. Maternal heart rate above 100 bpm
F. Bowel sounds in all four quadrants
Correct Answer: ABCD
Explanation; Magnesium sulfate is a CNS depressant and toxicity can lead to respiratory
arrest and cardiac arrest. Assessing DTRs, respiratory rate, and urine output (since the
drug is excreted renally) is critical for monitoring for toxicity. Therapeutic range
monitoring ensures the dose is effective without being lethal.
, 5. A 4-year-old child is admitted with suspected acute epiglottitis. Which of the following
nursing interventions is the highest priority?
A. Obtain a throat culture to identify the causative organism.
B. Ensure emergency airway equipment is at the bedside.
C. Place the child in a supine position to facilitate breathing.
D. Administer oral fluids to keep the child hydrated.
Correct Answer: B
Explanation; Acute epiglottitis is a medical emergency that can lead to sudden and
complete airway obstruction. Any attempt to visualize the throat or obtain a culture can
trigger a laryngospasm. The nurse must prioritize airway management and keep the child
calm in an upright position.
6. A nurse is caring for a newborn 15 minutes after birth. Which of the following is a normal
assessment finding?
A. Generalized cyanosis of the trunk and extremities.
B. Respiratory rate of 70 breaths per minute.
C. Heart rate of 140 beats per minute.
D. Presence of nasal flaring and grunting.
Correct Answer: C
418 / NUR 415 Nursing Care of the
Childbearing & Childrearing Family |
Actual Q&A with Rationale
(NUR418/NUR415 Final Exam) | Concordia
1. A nurse is assessing a postpartum client 2 hours after delivery and notes that the fundus is
firm, midline, and at the level of the umbilicus, but there is heavy vaginal bleeding. Which of
the following actions should the nurse take first?
A. Massage the uterine fundus vigorously.
B. Check the client’s vital signs.
C. Notify the healthcare provider of potential cervical laceration.
D. Assess for a full bladder and encourage the client to void.
Correct Answer: C
Explanation; In a postpartum client with heavy bleeding and a firm, midline fundus, the
most likely cause of bleeding is a cervical or vaginal laceration rather than uterine atony.
Massaging a firm fundus is unnecessary and potentially harmful to the tissue. The nurse
should immediately notify the provider to assess for trauma that requires repair.
,2. A nurse is providing discharge instructions to a parent of an infant with a newly diagnosed
ventricular septal defect (VSD). Which statement by the parent indicates a need for further
teaching?
A. ‘I should expect my baby to be on a fluid restriction to prevent heart failure.’
B. ‘I will monitor my baby for rapid breathing and poor feeding.’
C. ‘We will need to keep our follow-up appointments with the cardiologist.’
D. ‘My baby might need extra calories added to their formula.’
Correct Answer: A
Explanation; Infants with VSD and significant shunting are at risk for heart failure, but
they are typically not placed on strict fluid restrictions because they require adequate
hydration and high caloric intake to support growth. Managing nutrition is a priority
because these infants often tire easily during feeding. Monitoring for respiratory distress
and following up with specialists are essential components of care.
3. Which of the following findings in a pregnant client at 34 weeks gestation should the nurse
report to the healthcare provider immediately?
A. Blurry vision and a persistent headache.
B. Leukorrhea and increased vaginal discharge.
C. Swelling of the ankles at the end of the day.
D. Backache that improves with rest.
,Correct Answer: A
Explanation; Blurry vision and persistent headaches are classic warning signs of
preeclampsia, which can progress to eclampsia or HELLP syndrome. While ankle edema is
common in late pregnancy, it is the systemic symptoms of hypertension that are most
concerning. Prompt evaluation of blood pressure and urine protein is required for safety.
4. Select All That Apply (SATA): A nurse is preparing to administer Magnesium Sulfate to a
client for seizure prophylaxis in preeclampsia. Which of the following assessments are
mandatory before and during administration?
A. Presence of deep tendon reflexes (DTRs)
B. Respiratory rate of at least 12 breaths per minute
C. Urine output of at least 30 mL/hr
D. Serum magnesium levels within therapeutic range
E. Maternal heart rate above 100 bpm
F. Bowel sounds in all four quadrants
Correct Answer: ABCD
Explanation; Magnesium sulfate is a CNS depressant and toxicity can lead to respiratory
arrest and cardiac arrest. Assessing DTRs, respiratory rate, and urine output (since the
drug is excreted renally) is critical for monitoring for toxicity. Therapeutic range
monitoring ensures the dose is effective without being lethal.
, 5. A 4-year-old child is admitted with suspected acute epiglottitis. Which of the following
nursing interventions is the highest priority?
A. Obtain a throat culture to identify the causative organism.
B. Ensure emergency airway equipment is at the bedside.
C. Place the child in a supine position to facilitate breathing.
D. Administer oral fluids to keep the child hydrated.
Correct Answer: B
Explanation; Acute epiglottitis is a medical emergency that can lead to sudden and
complete airway obstruction. Any attempt to visualize the throat or obtain a culture can
trigger a laryngospasm. The nurse must prioritize airway management and keep the child
calm in an upright position.
6. A nurse is caring for a newborn 15 minutes after birth. Which of the following is a normal
assessment finding?
A. Generalized cyanosis of the trunk and extremities.
B. Respiratory rate of 70 breaths per minute.
C. Heart rate of 140 beats per minute.
D. Presence of nasal flaring and grunting.
Correct Answer: C
