NUR 418 / NUR 415 Exam 4 V2 | NUR 418 /
NUR 415 Nursing Care of the Childbearing
& Childrearing Family | Actual Q&A with
Rationale (NUR418/NUR415 Exam 4) |
Concordia
1. A nurse is caring for a 4-year-old child with a suspected diagnosis of epiglottitis. Which of
the following actions should the nurse prioritize?
A. Obtain a throat culture immediately
B. Perform a visual inspection of the throat with a tongue blade
C. Place the child in a supine position
D. Prepare for emergency airway placement
Correct Answer: D
Explanation; Epiglottitis is a medical emergency that can lead to sudden total airway
obstruction. Attempting to visualize the throat or obtain a culture can trigger a
laryngospasm, which is life-threatening. The nurse must prioritize having emergency
intubation or tracheostomy equipment at the bedside while keeping the child calm.
2. Which of the following findings should the nurse expect in a neonate diagnosed with
Tetralogy of Fallot? (Select All That Apply)
A. Cyanosis with crying
,B. Bounding peripheral pulses
C. Systolic murmur
D. Polycythemia
E. Clubbing of fingers
Correct Answer: A,C,D,E
Explanation; Tetralogy of Fallot involves four defects that lead to oxygen-poor blood
flowing to the body, causing cyanosis. Chronic hypoxia leads to compensatory
polycythemia and clubbing of the fingers over time. A systolic murmur is typically heard
due to the pulmonary stenosis component of the condition.
3. A postpartum nurse is assessing a client who delivered 12 hours ago. The nurse notes the
fundus is boggy and displaced to the right. What is the nurse’s first action?
A. Administer oxytocin as ordered
B. Assist the client to the bathroom to void
C. Massage the fundus until firm
D. Notify the primary healthcare provider
Correct Answer: B
Explanation; A fundus that is displaced to the right is a classic sign of bladder distension. A
full bladder prevents the uterus from contracting effectively, leading to uterine atony and
, increased bleeding. After the client voids, the nurse should reassess the fundal position and
firmness.
4. A nurse is providing discharge teaching to the parents of a child with Sickle Cell Anemia.
Which instruction is most important to include for preventing a vaso-occlusive crisis?
A. Maintain adequate hydration throughout the day
B. Limit the child’s fluid intake at night
C. Avoid all forms of physical exercise
D. Administer aspirin for any pain reported
Correct Answer: A
Explanation; Hydration is the most critical intervention to prevent the sickling of red
blood cells by reducing blood viscosity. Parents should be taught to encourage fluids even
when the child is not thirsty. Dehydration, infection, and low oxygen levels are common
triggers for a crisis.
5. A 6-month-old infant is admitted with pyloric stenosis. Which clinical manifestation should
the nurse anticipate?
A. Projectile vomiting after feedings
B. Currant jelly-like stools
C. Biliary-stained emesis
D. Abdominal distension and diarrhea
NUR 415 Nursing Care of the Childbearing
& Childrearing Family | Actual Q&A with
Rationale (NUR418/NUR415 Exam 4) |
Concordia
1. A nurse is caring for a 4-year-old child with a suspected diagnosis of epiglottitis. Which of
the following actions should the nurse prioritize?
A. Obtain a throat culture immediately
B. Perform a visual inspection of the throat with a tongue blade
C. Place the child in a supine position
D. Prepare for emergency airway placement
Correct Answer: D
Explanation; Epiglottitis is a medical emergency that can lead to sudden total airway
obstruction. Attempting to visualize the throat or obtain a culture can trigger a
laryngospasm, which is life-threatening. The nurse must prioritize having emergency
intubation or tracheostomy equipment at the bedside while keeping the child calm.
2. Which of the following findings should the nurse expect in a neonate diagnosed with
Tetralogy of Fallot? (Select All That Apply)
A. Cyanosis with crying
,B. Bounding peripheral pulses
C. Systolic murmur
D. Polycythemia
E. Clubbing of fingers
Correct Answer: A,C,D,E
Explanation; Tetralogy of Fallot involves four defects that lead to oxygen-poor blood
flowing to the body, causing cyanosis. Chronic hypoxia leads to compensatory
polycythemia and clubbing of the fingers over time. A systolic murmur is typically heard
due to the pulmonary stenosis component of the condition.
3. A postpartum nurse is assessing a client who delivered 12 hours ago. The nurse notes the
fundus is boggy and displaced to the right. What is the nurse’s first action?
A. Administer oxytocin as ordered
B. Assist the client to the bathroom to void
C. Massage the fundus until firm
D. Notify the primary healthcare provider
Correct Answer: B
Explanation; A fundus that is displaced to the right is a classic sign of bladder distension. A
full bladder prevents the uterus from contracting effectively, leading to uterine atony and
, increased bleeding. After the client voids, the nurse should reassess the fundal position and
firmness.
4. A nurse is providing discharge teaching to the parents of a child with Sickle Cell Anemia.
Which instruction is most important to include for preventing a vaso-occlusive crisis?
A. Maintain adequate hydration throughout the day
B. Limit the child’s fluid intake at night
C. Avoid all forms of physical exercise
D. Administer aspirin for any pain reported
Correct Answer: A
Explanation; Hydration is the most critical intervention to prevent the sickling of red
blood cells by reducing blood viscosity. Parents should be taught to encourage fluids even
when the child is not thirsty. Dehydration, infection, and low oxygen levels are common
triggers for a crisis.
5. A 6-month-old infant is admitted with pyloric stenosis. Which clinical manifestation should
the nurse anticipate?
A. Projectile vomiting after feedings
B. Currant jelly-like stools
C. Biliary-stained emesis
D. Abdominal distension and diarrhea
