NIGHTINGALE BSN 366 EXAM 4 ACTUAL 300
QUESTIONS AND CORRECT ANSWERS WITH
RATIONALE LATEST UPDATE ALREADY GRADED A+
This comprehensive 300-question review for Nightingale BSN 366 Exam 4
(HESI RN Exit) covers maternity, medical-surgical, pharmacology, and
psychiatric nursing. Each unique multiple-choice question includes a correct
answer and a detailed, evidence-based rationale. Topics range from labor
complications, newborn assessment, and postpartum care to heart failure,
COPD, stroke, diabetes, and shock. Pharmacological content covers
anticoagulants, antibiotics, antipsychotics, and cardiac drugs with critical
monitoring parameters. Delegation, prioritization, and emergency triage
scenarios are also included. The rationales explain the "why" behind each
answer, reinforcing clinical reasoning and safety. This resource is designed to
strengthen test-taking skills and deepen understanding of high-yield NCLEX
concepts.
Question 1
A client in active labor experiences prolonged second stage. After the fetal head
delivers, it retracts tightly against the perineum and does not recede. Which action
should the nurse take immediately?
A. Apply gentle suprapubic pressure
B. Position the client in a hands-and-knees position
C. Call for assistance and prepare for shoulder dystocia maneuvers
D. Apply fundal pressure
Answer: C. Call for assistance and prepare for shoulder dystocia maneuvers
Rationale: The "turtle sign," where the fetal head retracts against the perineum, is a
classic sign of shoulder dystocia. The nurse should call for immediate assistance
and prepare for maneuvers such as the McRoberts maneuver and suprapubic
pressure. Fundal pressure is contraindicated as it can worsen the impaction .
Question 2
,The nurse is assessing a client receiving oxytocin for labor induction. Which
finding requires immediate intervention?
A. Contractions every 3 minutes lasting 60 seconds
B. Fetal heart rate of 160 bpm
C. Contractions every 2 minutes lasting 90 seconds
D. Maternal heart rate of 100 bpm
Answer: C. Contractions every 2 minutes lasting 90 seconds
Rationale: Contractions lasting more than 90 seconds or occurring more frequently
than every 2 minutes indicate uterine hyperstimulation. This can lead to fetal
distress and uterine rupture, so the oxytocin infusion should be stopped
immediately .
Question 3
A client with preeclampsia is receiving magnesium sulfate. Which assessment
finding indicates magnesium toxicity?
A. Respiratory rate of 16 breaths/min
B. Urine output of 40 mL/hr
C. Absent deep tendon reflexes
D. Serum magnesium level of 5 mEq/L
Answer: C. Absent deep tendon reflexes
Rationale: Absent deep tendon reflexes (DTRs) is a sign of magnesium toxicity.
Other signs include a respiratory rate below 12 breaths/min, urine output below 30
mL/hr, and serum magnesium levels above 7-8 mEq/L. The antidote is calcium
gluconate .
Question 4
A newborn is 2 hours old with a heart rate of 110 bpm, irregular respirations,
acrocyanosis, and a weak cry. What is the priority nursing action?
A. Administer oxygen via hood
B. Stimulate the newborn to cry
C. Assess the newborn's temperature
D. Document the findings
Answer: C. Assess the newborn's temperature
Rationale: Newborns lose heat rapidly after birth, and cold stress can cause
respiratory distress, hypoglycemia, and metabolic acidosis. Assessing and
maintaining a neutral thermal environment is the priority action .
Question 5
,A patient is admitted to the birthing unit with contractions occurring every 3-5
minutes and a cervix dilated to 4 cm. The nurse identifies the patient to be in which
phase of labor?
A. Latent phase
B. Active phase
C. Transition phase
D. Second stage
Answer: B. Active phase
Rationale: The active phase of labor is characterized by cervical dilation from 4 -7
cm, with contractions occurring every 2-5 minutes and moderate to strong
intensity. The latent phase is 0-3 cm, transition is 8-10 cm, and the second stage is
from full dilation to delivery .
Question 6
A newborn is 12 hours old and has not passed meconium. Which finding is most
concerning?
A. Bilious vomiting
B. Abdominal distention
C. Failure to pass meconium within 48 hours
D. All of the above
Answer: D. All of the above
Rationale: Failure to pass meconium within 24-48 hours, accompanied by bilious
vomiting and abdominal distention, may indicate an intestinal obstruction such as
meconium ileus or Hirschsprung's disease, which requires further evaluation .
Question 7
The nurse is teaching a client about breastfeeding. Which instruction is correct?
A. Breastfeeding should be initiated within the first hour after birth
B. Breastfeeding should be delayed until the mother is fully recovered
C. Breastfeeding should be initiated only after the first feeding
D. Breastfeeding should be delayed until the infant cries
Answer: A. Breastfeeding should be initiated within the first hour after birth
Rationale: Early initiation of breastfeeding within the first hour after birth
promotes bonding, stimulates milk production, and provides colostrum. The infant
should be placed skin-to-skin with the mother as soon as possible after birth .
Question 8
A client with gestational diabetes is at risk for which newborn complication?
A. Hyperglycemia
B. Hypoglycemia
, C. Hypercalcemia
D. Hyperbilirubinemia
Answer: B. Hypoglycemia
Rationale: Infants of diabetic mothers (IDMs) are at risk for hypoglycemia due to
hyperinsulinemia. The newborn's insulin production continues after birth, leading
to low blood glucose levels. Early feeding and glucose monitoring are essential .
Question 9
The nurse is assessing a newborn for jaundice. Which finding indicates
pathological jaundice?
A. Jaundice appearing at 24 hours of age
B. Jaundice appearing at 48 hours of age
C. Jaundice appearing at 72 hours of age
D. Jaundice appearing at 96 hours of age
Answer: A. Jaundice appearing at 24 hours of age
Rationale: Pathological jaundice appears within the first 24 hours of life and
requires further evaluation. Physiologic jaundice typically appears after 24 hours
and peaks around 3-5 days of life .
Question 10
A client with a history of preterm labor is receiving betamethasone. The nurse
understands that the purpose of this medication is to:
A. Stop uterine contractions
B. Promote fetal lung maturity
C. Reduce the risk of preeclampsia
D. Prevent maternal infection
Answer: B. Promote fetal lung maturity
Rationale: Betamethasone is a corticosteroid administered to pregnant women at
risk of preterm delivery between 24 and 34 weeks of gestation to accelera te fetal
lung maturity and reduce the risk of respiratory distress syndrome .
Question 11
A newborn is 24 hours old with a respiratory rate of 70 breaths/min, nasal flaring,
and grunting. Which action should the nurse take?
A. Administer oxygen via hood
B. Suction the airway
C. Notify the provider immediately
D. Place the newborn in a warm environment
Answer: C. Notify the provider immediately
QUESTIONS AND CORRECT ANSWERS WITH
RATIONALE LATEST UPDATE ALREADY GRADED A+
This comprehensive 300-question review for Nightingale BSN 366 Exam 4
(HESI RN Exit) covers maternity, medical-surgical, pharmacology, and
psychiatric nursing. Each unique multiple-choice question includes a correct
answer and a detailed, evidence-based rationale. Topics range from labor
complications, newborn assessment, and postpartum care to heart failure,
COPD, stroke, diabetes, and shock. Pharmacological content covers
anticoagulants, antibiotics, antipsychotics, and cardiac drugs with critical
monitoring parameters. Delegation, prioritization, and emergency triage
scenarios are also included. The rationales explain the "why" behind each
answer, reinforcing clinical reasoning and safety. This resource is designed to
strengthen test-taking skills and deepen understanding of high-yield NCLEX
concepts.
Question 1
A client in active labor experiences prolonged second stage. After the fetal head
delivers, it retracts tightly against the perineum and does not recede. Which action
should the nurse take immediately?
A. Apply gentle suprapubic pressure
B. Position the client in a hands-and-knees position
C. Call for assistance and prepare for shoulder dystocia maneuvers
D. Apply fundal pressure
Answer: C. Call for assistance and prepare for shoulder dystocia maneuvers
Rationale: The "turtle sign," where the fetal head retracts against the perineum, is a
classic sign of shoulder dystocia. The nurse should call for immediate assistance
and prepare for maneuvers such as the McRoberts maneuver and suprapubic
pressure. Fundal pressure is contraindicated as it can worsen the impaction .
Question 2
,The nurse is assessing a client receiving oxytocin for labor induction. Which
finding requires immediate intervention?
A. Contractions every 3 minutes lasting 60 seconds
B. Fetal heart rate of 160 bpm
C. Contractions every 2 minutes lasting 90 seconds
D. Maternal heart rate of 100 bpm
Answer: C. Contractions every 2 minutes lasting 90 seconds
Rationale: Contractions lasting more than 90 seconds or occurring more frequently
than every 2 minutes indicate uterine hyperstimulation. This can lead to fetal
distress and uterine rupture, so the oxytocin infusion should be stopped
immediately .
Question 3
A client with preeclampsia is receiving magnesium sulfate. Which assessment
finding indicates magnesium toxicity?
A. Respiratory rate of 16 breaths/min
B. Urine output of 40 mL/hr
C. Absent deep tendon reflexes
D. Serum magnesium level of 5 mEq/L
Answer: C. Absent deep tendon reflexes
Rationale: Absent deep tendon reflexes (DTRs) is a sign of magnesium toxicity.
Other signs include a respiratory rate below 12 breaths/min, urine output below 30
mL/hr, and serum magnesium levels above 7-8 mEq/L. The antidote is calcium
gluconate .
Question 4
A newborn is 2 hours old with a heart rate of 110 bpm, irregular respirations,
acrocyanosis, and a weak cry. What is the priority nursing action?
A. Administer oxygen via hood
B. Stimulate the newborn to cry
C. Assess the newborn's temperature
D. Document the findings
Answer: C. Assess the newborn's temperature
Rationale: Newborns lose heat rapidly after birth, and cold stress can cause
respiratory distress, hypoglycemia, and metabolic acidosis. Assessing and
maintaining a neutral thermal environment is the priority action .
Question 5
,A patient is admitted to the birthing unit with contractions occurring every 3-5
minutes and a cervix dilated to 4 cm. The nurse identifies the patient to be in which
phase of labor?
A. Latent phase
B. Active phase
C. Transition phase
D. Second stage
Answer: B. Active phase
Rationale: The active phase of labor is characterized by cervical dilation from 4 -7
cm, with contractions occurring every 2-5 minutes and moderate to strong
intensity. The latent phase is 0-3 cm, transition is 8-10 cm, and the second stage is
from full dilation to delivery .
Question 6
A newborn is 12 hours old and has not passed meconium. Which finding is most
concerning?
A. Bilious vomiting
B. Abdominal distention
C. Failure to pass meconium within 48 hours
D. All of the above
Answer: D. All of the above
Rationale: Failure to pass meconium within 24-48 hours, accompanied by bilious
vomiting and abdominal distention, may indicate an intestinal obstruction such as
meconium ileus or Hirschsprung's disease, which requires further evaluation .
Question 7
The nurse is teaching a client about breastfeeding. Which instruction is correct?
A. Breastfeeding should be initiated within the first hour after birth
B. Breastfeeding should be delayed until the mother is fully recovered
C. Breastfeeding should be initiated only after the first feeding
D. Breastfeeding should be delayed until the infant cries
Answer: A. Breastfeeding should be initiated within the first hour after birth
Rationale: Early initiation of breastfeeding within the first hour after birth
promotes bonding, stimulates milk production, and provides colostrum. The infant
should be placed skin-to-skin with the mother as soon as possible after birth .
Question 8
A client with gestational diabetes is at risk for which newborn complication?
A. Hyperglycemia
B. Hypoglycemia
, C. Hypercalcemia
D. Hyperbilirubinemia
Answer: B. Hypoglycemia
Rationale: Infants of diabetic mothers (IDMs) are at risk for hypoglycemia due to
hyperinsulinemia. The newborn's insulin production continues after birth, leading
to low blood glucose levels. Early feeding and glucose monitoring are essential .
Question 9
The nurse is assessing a newborn for jaundice. Which finding indicates
pathological jaundice?
A. Jaundice appearing at 24 hours of age
B. Jaundice appearing at 48 hours of age
C. Jaundice appearing at 72 hours of age
D. Jaundice appearing at 96 hours of age
Answer: A. Jaundice appearing at 24 hours of age
Rationale: Pathological jaundice appears within the first 24 hours of life and
requires further evaluation. Physiologic jaundice typically appears after 24 hours
and peaks around 3-5 days of life .
Question 10
A client with a history of preterm labor is receiving betamethasone. The nurse
understands that the purpose of this medication is to:
A. Stop uterine contractions
B. Promote fetal lung maturity
C. Reduce the risk of preeclampsia
D. Prevent maternal infection
Answer: B. Promote fetal lung maturity
Rationale: Betamethasone is a corticosteroid administered to pregnant women at
risk of preterm delivery between 24 and 34 weeks of gestation to accelera te fetal
lung maturity and reduce the risk of respiratory distress syndrome .
Question 11
A newborn is 24 hours old with a respiratory rate of 70 breaths/min, nasal flaring,
and grunting. Which action should the nurse take?
A. Administer oxygen via hood
B. Suction the airway
C. Notify the provider immediately
D. Place the newborn in a warm environment
Answer: C. Notify the provider immediately
