NUR 418 / NUR 415 Final Exam V1 | 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 client who is in the first stage of labor. Which of the following
findings should the nurse identify as a cause for concern?
A. Fetal heart rate baseline of 140/min
B. Clear vaginal fluid with a pH of 7.0
C. Early decelerations during contractions
D. Late decelerations on the fetal monitor
Correct Answer: D
Explanation; Late decelerations are indicative of uteroplacental insufficiency, which can
lead to fetal hypoxia and metabolic acidosis. This is a non-reassuring fetal heart rate
pattern that requires immediate nursing intervention such as repositioning the mother or
administering oxygen. Early decelerations, conversely, are typically caused by fetal head
compression and are considered benign.
2. A nurse is caring for a newborn who was born at 38 weeks of gestation. Which of the
following findings is indicative of respiratory distress in the neonate?
A. Respiratory rate of 50 breaths per minute
,B. Acrocyanosis of the hands and feet
C. Nasal flaring and grunting
D. Brief periods of apnea lasting 5 seconds
Correct Answer: C
Explanation; Nasal flaring, grunting, and intercostal retractions are classic signs of
respiratory distress in a newborn as the infant attempts to maintain airway patency.
Acrocyanosis is a normal finding in the first 24-48 hours of life due to poor peripheral
circulation. A respiratory rate between 30 and 60 is considered within the normal range for
a neonate.
3. A client is 2 hours postpartum and the nurse notes that the client’s fundus is boggy and
displaced to the right. Which of the following actions should the nurse take first?
A. Administer oxytocin IV bolus
B. Notify the provider of the displacement
C. Massage the fundus until firm
D. Assist the client to the bathroom to void
Correct Answer: D
Explanation; A fundus that is displaced to the right or left usually indicates a distended
bladder, which prevents the uterus from contracting effectively. Assisting the client to void
will allow the bladder to empty, enabling the fundus to return to the midline and firm up.
,While fundal massage is important for a boggy uterus, addressing the bladder distention is
the specific intervention for displacement.
4. A nurse is providing teaching to the parents of a 4-year-old child about safety. Which of the
following statements by the parents indicates an understanding of the teaching?
A. We should use a booster seat until our child is 4 feet 9 inches tall.
B. Our child can ride in the front seat as long as the airbag is off.
C. Helmets are only necessary when riding on the street.
D. We can stop monitoring our child near the pool since they had swimming lessons.
Correct Answer: A
Explanation; Children should remain in a booster seat until they reach a height of
approximately 4 feet 9 inches (145 cm) and are between 8 and 12 years of age. This
ensures that the vehicle lap and shoulder belts fit properly across the strongest parts of the
child’s body. Swimming lessons do not replace the need for constant adult supervision near
water, and children should always wear helmets when using wheeled toys.
5. Which of the following is the most appropriate nursing intervention for a child
experiencing a vaso-occlusive crisis due to sickle cell anemia?
A. Applying cold compresses to the painful joints
B. Administering aspirin for pain management
C. Restricting oral fluid intake to prevent edema
, D. Administering high volumes of intravenous fluids
Correct Answer: D
Explanation; Hydration is a priority intervention during a sickle cell crisis to reduce the
viscosity of the blood and help prevent further sickling of cells. Pain management is also
critical, but it typically involves opioids rather than aspirin due to the risk of Reye’s
syndrome in children. Cold compresses should be avoided because they cause
vasoconstriction, which further impairs blood flow.
6. A nurse is assessing a child with suspected epiglottitis. Which of the following actions
should the nurse avoid?
A. Assessing the child’s pulse oximetry
B. Inspecting the throat with a tongue blade
C. Encouraging the child to sit in a tripod position
D. Administering humidified oxygen
Correct Answer: B
Explanation; Inspecting the throat of a child with suspected epiglottitis using a tongue
blade can trigger a laryngospasm and lead to complete airway obstruction. The child
should be kept calm and allowed to remain in a position of comfort, usually sitting upright
or in a tripod position. Immediate medical attention and prepared intubation equipment
are necessary for this life-threatening emergency.
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 client who is in the first stage of labor. Which of the following
findings should the nurse identify as a cause for concern?
A. Fetal heart rate baseline of 140/min
B. Clear vaginal fluid with a pH of 7.0
C. Early decelerations during contractions
D. Late decelerations on the fetal monitor
Correct Answer: D
Explanation; Late decelerations are indicative of uteroplacental insufficiency, which can
lead to fetal hypoxia and metabolic acidosis. This is a non-reassuring fetal heart rate
pattern that requires immediate nursing intervention such as repositioning the mother or
administering oxygen. Early decelerations, conversely, are typically caused by fetal head
compression and are considered benign.
2. A nurse is caring for a newborn who was born at 38 weeks of gestation. Which of the
following findings is indicative of respiratory distress in the neonate?
A. Respiratory rate of 50 breaths per minute
,B. Acrocyanosis of the hands and feet
C. Nasal flaring and grunting
D. Brief periods of apnea lasting 5 seconds
Correct Answer: C
Explanation; Nasal flaring, grunting, and intercostal retractions are classic signs of
respiratory distress in a newborn as the infant attempts to maintain airway patency.
Acrocyanosis is a normal finding in the first 24-48 hours of life due to poor peripheral
circulation. A respiratory rate between 30 and 60 is considered within the normal range for
a neonate.
3. A client is 2 hours postpartum and the nurse notes that the client’s fundus is boggy and
displaced to the right. Which of the following actions should the nurse take first?
A. Administer oxytocin IV bolus
B. Notify the provider of the displacement
C. Massage the fundus until firm
D. Assist the client to the bathroom to void
Correct Answer: D
Explanation; A fundus that is displaced to the right or left usually indicates a distended
bladder, which prevents the uterus from contracting effectively. Assisting the client to void
will allow the bladder to empty, enabling the fundus to return to the midline and firm up.
,While fundal massage is important for a boggy uterus, addressing the bladder distention is
the specific intervention for displacement.
4. A nurse is providing teaching to the parents of a 4-year-old child about safety. Which of the
following statements by the parents indicates an understanding of the teaching?
A. We should use a booster seat until our child is 4 feet 9 inches tall.
B. Our child can ride in the front seat as long as the airbag is off.
C. Helmets are only necessary when riding on the street.
D. We can stop monitoring our child near the pool since they had swimming lessons.
Correct Answer: A
Explanation; Children should remain in a booster seat until they reach a height of
approximately 4 feet 9 inches (145 cm) and are between 8 and 12 years of age. This
ensures that the vehicle lap and shoulder belts fit properly across the strongest parts of the
child’s body. Swimming lessons do not replace the need for constant adult supervision near
water, and children should always wear helmets when using wheeled toys.
5. Which of the following is the most appropriate nursing intervention for a child
experiencing a vaso-occlusive crisis due to sickle cell anemia?
A. Applying cold compresses to the painful joints
B. Administering aspirin for pain management
C. Restricting oral fluid intake to prevent edema
, D. Administering high volumes of intravenous fluids
Correct Answer: D
Explanation; Hydration is a priority intervention during a sickle cell crisis to reduce the
viscosity of the blood and help prevent further sickling of cells. Pain management is also
critical, but it typically involves opioids rather than aspirin due to the risk of Reye’s
syndrome in children. Cold compresses should be avoided because they cause
vasoconstriction, which further impairs blood flow.
6. A nurse is assessing a child with suspected epiglottitis. Which of the following actions
should the nurse avoid?
A. Assessing the child’s pulse oximetry
B. Inspecting the throat with a tongue blade
C. Encouraging the child to sit in a tripod position
D. Administering humidified oxygen
Correct Answer: B
Explanation; Inspecting the throat of a child with suspected epiglottitis using a tongue
blade can trigger a laryngospasm and lead to complete airway obstruction. The child
should be kept calm and allowed to remain in a position of comfort, usually sitting upright
or in a tripod position. Immediate medical attention and prepared intubation equipment
are necessary for this life-threatening emergency.
