NUR 231 Final Exam Actual Exam V3 | NUR 231 Childbearing & Child
Caring Family (NUR231 Final Exam) | Galen College of Nursing
1. A nurse is caring for a client at 34 weeks gestation diagnosed with severe preeclampsia.
Which of the following assessment findings would be the highest priority to report to the
provider?
A. 1+ pitting edema in the lower extremities
B. A blood pressure reading of 150/96 mmHg
C. Epigastric pain and right upper quadrant tenderness
D. Urinary output of 40 mL per hour
Answer: C
Rationale: Epigastric pain in a preeclamptic client often indicates liver involvement
(distention of the hepatic capsule) and can be a precursor to HELLP syndrome or seizure
activity (eclampsia). This comprehensive analysis demonstrates that prioritization must
focus on signs of impending multi-organ failure. The nurse must synthesize physiological
data to prevent catastrophic maternal outcomes like liver rupture.
2. During the active phase of labor, the fetal heart rate monitor shows late decelerations.
Which nursing action should be performed first?
A. Increase the rate of the oxytocin infusion
B. Perform a sterile vaginal examination
C. Obtain a maternal temperature
D. Reposition the client to a lateral position
Answer: D
Rationale: Late decelerations indicate uteroplacental insufficiency. Repositioning the
mother to her side (lateral) improves blood flow to the placenta by relieving pressure on
the vena cava. This is a critical clinical reasoning step in fetal resuscitation.
3. A 4-year-old child is admitted to the pediatric unit with suspected acute epiglottitis. Which
nursing intervention is contraindicated?
A. Placing the child in a high-Fowler’s position
B. Obtaining a throat culture using a sterile swab
C. Monitoring oxygen saturation levels continuously
D. Preparing for emergency intubation
,Answer: B
Rationale: In a child with suspected epiglottitis, nothing should be placed in the mouth
(like a tongue blade or swab) as this can trigger a laryngospasm and complete airway
obstruction. Airway management and safety are the primary concerns in this life-
threatening pediatric complication.
4. A postpartum client who is breastfeeding is being discharged. Which statement by the
client indicates a need for further education regarding mastitis?
A. I should wear a supportive bra without underwires.
B. I need to wash my hands thoroughly before each feeding.
C. I will try to empty my breasts completely during each feeding.
D. If I develop a red, painful area on my breast, I should stop breastfeeding immediately.
Answer: D
Rationale: Stopping breastfeeding abruptly during mastitis can lead to milk stasis and
worsen the infection or lead to an abscess. The client should continue to nurse or pump to
maintain milk flow. Education focuses on infection control and proper emptying of the
breast.
5. A nurse is assessing a 2-month-old infant. According to Erikson’s stages of psychosocial
development, which task is the infant working to achieve?
A. Autonomy vs. Shame and Doubt
B. Initiative vs. Guilt
C. Trust vs. Mistrust
D. Industry vs. Inferiority
Answer: C
Rationale: The stage for infants (birth to 1 year) is Trust vs. Mistrust. The infant learns to
trust that their needs will be met by caregivers. This synthesis of developmental theory is
essential for pediatric nursing care.
6. A client at 32 weeks gestation presents with painless, bright red vaginal bleeding. The
nurse should prioritize which diagnostic evaluation?
A. Transvaginal ultrasound
B. Vaginal exam to check for cervical dilation
C. Contraction stress test (CST)
D. Abdominal ultrasound
Answer: D
, Rationale: Painless bright red bleeding is a classic sign of placenta previa. A vaginal exam
is strictly contraindicated until placenta previa is ruled out, as it can cause massive
hemorrhage. Abdominal ultrasound is the safest way to determine placental location.
7. A nurse is teaching the parents of a child with cystic fibrosis about their child’s nutritional
needs. Which instruction should be included?
A. Restrict salt intake to prevent fluid retention.
B. Limit fluid intake during meals to improve digestion.
C. Follow a low-fat, low-calorie diet.
D. Administer pancreatic enzymes with every meal and snack.
Answer: D
Rationale: Children with cystic fibrosis have pancreatic insufficiency and require
replacement enzymes to digest fats and proteins. They generally need a high-protein, high-
calorie, and unrestricted-fat diet with adequate sodium intake.
8. A newborn is 5 minutes old. The nurse observes: HR 110, loud crying, some flexion of
extremities, sneezing when stimulated, and bluish hands and feet. What is the Apgar score?
A. 8
B. 7
C. 9
D. 10
Answer: A
Rationale: HR >100 (2 pts), Crying (2 pts), Some flexion (1 pt), Sneezing/Grimace (2 pts),
Acrocyanosis (1 pt). Total = 8. This assesses the immediate transition of the newborn to
extrauterine life.
9. Which clinical finding in a 6-month-old infant would require immediate intervention by the
nurse?
A. Inability to sit without support
B. Intercostal retractions and nasal flaring
C. Absence of the Babinski reflex
D. Closure of the posterior fontanel
Answer: B
Rationale: Retractions and nasal flaring are signs of respiratory distress in an infant, which
can lead to rapid decompensation. Sitting without support is an 8-month milestone;
Babinski disappears around 1 year; posterior fontanel closes at 2-3 months.
Caring Family (NUR231 Final Exam) | Galen College of Nursing
1. A nurse is caring for a client at 34 weeks gestation diagnosed with severe preeclampsia.
Which of the following assessment findings would be the highest priority to report to the
provider?
A. 1+ pitting edema in the lower extremities
B. A blood pressure reading of 150/96 mmHg
C. Epigastric pain and right upper quadrant tenderness
D. Urinary output of 40 mL per hour
Answer: C
Rationale: Epigastric pain in a preeclamptic client often indicates liver involvement
(distention of the hepatic capsule) and can be a precursor to HELLP syndrome or seizure
activity (eclampsia). This comprehensive analysis demonstrates that prioritization must
focus on signs of impending multi-organ failure. The nurse must synthesize physiological
data to prevent catastrophic maternal outcomes like liver rupture.
2. During the active phase of labor, the fetal heart rate monitor shows late decelerations.
Which nursing action should be performed first?
A. Increase the rate of the oxytocin infusion
B. Perform a sterile vaginal examination
C. Obtain a maternal temperature
D. Reposition the client to a lateral position
Answer: D
Rationale: Late decelerations indicate uteroplacental insufficiency. Repositioning the
mother to her side (lateral) improves blood flow to the placenta by relieving pressure on
the vena cava. This is a critical clinical reasoning step in fetal resuscitation.
3. A 4-year-old child is admitted to the pediatric unit with suspected acute epiglottitis. Which
nursing intervention is contraindicated?
A. Placing the child in a high-Fowler’s position
B. Obtaining a throat culture using a sterile swab
C. Monitoring oxygen saturation levels continuously
D. Preparing for emergency intubation
,Answer: B
Rationale: In a child with suspected epiglottitis, nothing should be placed in the mouth
(like a tongue blade or swab) as this can trigger a laryngospasm and complete airway
obstruction. Airway management and safety are the primary concerns in this life-
threatening pediatric complication.
4. A postpartum client who is breastfeeding is being discharged. Which statement by the
client indicates a need for further education regarding mastitis?
A. I should wear a supportive bra without underwires.
B. I need to wash my hands thoroughly before each feeding.
C. I will try to empty my breasts completely during each feeding.
D. If I develop a red, painful area on my breast, I should stop breastfeeding immediately.
Answer: D
Rationale: Stopping breastfeeding abruptly during mastitis can lead to milk stasis and
worsen the infection or lead to an abscess. The client should continue to nurse or pump to
maintain milk flow. Education focuses on infection control and proper emptying of the
breast.
5. A nurse is assessing a 2-month-old infant. According to Erikson’s stages of psychosocial
development, which task is the infant working to achieve?
A. Autonomy vs. Shame and Doubt
B. Initiative vs. Guilt
C. Trust vs. Mistrust
D. Industry vs. Inferiority
Answer: C
Rationale: The stage for infants (birth to 1 year) is Trust vs. Mistrust. The infant learns to
trust that their needs will be met by caregivers. This synthesis of developmental theory is
essential for pediatric nursing care.
6. A client at 32 weeks gestation presents with painless, bright red vaginal bleeding. The
nurse should prioritize which diagnostic evaluation?
A. Transvaginal ultrasound
B. Vaginal exam to check for cervical dilation
C. Contraction stress test (CST)
D. Abdominal ultrasound
Answer: D
, Rationale: Painless bright red bleeding is a classic sign of placenta previa. A vaginal exam
is strictly contraindicated until placenta previa is ruled out, as it can cause massive
hemorrhage. Abdominal ultrasound is the safest way to determine placental location.
7. A nurse is teaching the parents of a child with cystic fibrosis about their child’s nutritional
needs. Which instruction should be included?
A. Restrict salt intake to prevent fluid retention.
B. Limit fluid intake during meals to improve digestion.
C. Follow a low-fat, low-calorie diet.
D. Administer pancreatic enzymes with every meal and snack.
Answer: D
Rationale: Children with cystic fibrosis have pancreatic insufficiency and require
replacement enzymes to digest fats and proteins. They generally need a high-protein, high-
calorie, and unrestricted-fat diet with adequate sodium intake.
8. A newborn is 5 minutes old. The nurse observes: HR 110, loud crying, some flexion of
extremities, sneezing when stimulated, and bluish hands and feet. What is the Apgar score?
A. 8
B. 7
C. 9
D. 10
Answer: A
Rationale: HR >100 (2 pts), Crying (2 pts), Some flexion (1 pt), Sneezing/Grimace (2 pts),
Acrocyanosis (1 pt). Total = 8. This assesses the immediate transition of the newborn to
extrauterine life.
9. Which clinical finding in a 6-month-old infant would require immediate intervention by the
nurse?
A. Inability to sit without support
B. Intercostal retractions and nasal flaring
C. Absence of the Babinski reflex
D. Closure of the posterior fontanel
Answer: B
Rationale: Retractions and nasal flaring are signs of respiratory distress in an infant, which
can lead to rapid decompensation. Sitting without support is an 8-month milestone;
Babinski disappears around 1 year; posterior fontanel closes at 2-3 months.
