NUR231 Exam 3 V1 | NUR 231
Childbearing & Child Caring Family Exam
Q&A | Galen College of Nursing
1. A nurse is assessing a client 2 hours postpartum and finds the fundus is boggy and
displaced to the right. What is the priority nursing action?
A. Encourage the client to void
B. Perform fundal massage
C. Administer oxytocin as ordered
D. Document the finding as normal
Answer: A
Rationale: A displaced fundus to the right is a classic sign of a distended bladder. A full
bladder prevents the uterus from contracting effectively, which increases the risk of
hemorrhage. Encouraging the client to void or catheterizing them will allow the uterus to
return to the midline and firm up.
2. Which Erikson stage of psychosocial development is characteristic of a 4-year-old child?
A. Trust vs. Mistrust
B. Autonomy vs. Shame and Doubt
C. Initiative vs. Guilt
D. Industry vs. Inferiority
,Answer: C
Rationale: Preschool-aged children (3 to 6 years) are in the Initiative vs. Guilt stage.
During this time, they begin to assert power and control over the world through directing
play and other social interactions. Success in this stage leads to a sense of purpose, while
failure results in a sense of guilt.
3. A mother is concerned that her 6-month-old infant is not yet sitting unsupported. How
should the nurse respond?
A. Most infants begin to sit unsupported between 6 and 8 months.
B. Sitting unsupported is expected by 8 months of age.
C. This is a significant delay requiring immediate referral.
D. The infant should have achieved this milestone at 4 months.
Answer: A
Rationale: Developmental milestones have a range of normal achievement. Most infants
typically sit alone without support by 8 months, but they begin to practice and lean
forward on their hands (tripod sit) around 6 months. Providing reassurance while
monitoring progress is the appropriate nursing response.
4. What is the most effective way to prevent the spread of infection in a newborn nursery?
A. Wearing a mask at all times
B. Keeping infants in separate isolettes
, C. Strict hand hygiene practices
D. Prohibiting all visitors
Answer: C
Rationale: Hand hygiene is the single most important measure to prevent the transmission
of pathogens in the healthcare setting. Nurses must wash their hands before and after
every patient contact. This is especially critical in the newborn population due to their
immature immune systems.
5. Which of the following is an expected physical finding in a healthy 2-day-old newborn?
A. Posterior fontanelle closure
B. Regurgitation of all feedings
C. Positive Babinski reflex
D. Heart rate of 80 beats per minute
Answer: C
Rationale: The Babinski reflex is a normal finding in newborns and infants up to age 2. It
involves the fanning out of the toes when the sole of the foot is stroked. Other options like a
heart rate of 80 or constant regurgitation would be considered abnormal.
6. A postpartum client reports sharp calf pain that increases with dorsiflexion. What should
the nurse suspect?
A. Normal postpartum muscle soreness
Childbearing & Child Caring Family Exam
Q&A | Galen College of Nursing
1. A nurse is assessing a client 2 hours postpartum and finds the fundus is boggy and
displaced to the right. What is the priority nursing action?
A. Encourage the client to void
B. Perform fundal massage
C. Administer oxytocin as ordered
D. Document the finding as normal
Answer: A
Rationale: A displaced fundus to the right is a classic sign of a distended bladder. A full
bladder prevents the uterus from contracting effectively, which increases the risk of
hemorrhage. Encouraging the client to void or catheterizing them will allow the uterus to
return to the midline and firm up.
2. Which Erikson stage of psychosocial development is characteristic of a 4-year-old child?
A. Trust vs. Mistrust
B. Autonomy vs. Shame and Doubt
C. Initiative vs. Guilt
D. Industry vs. Inferiority
,Answer: C
Rationale: Preschool-aged children (3 to 6 years) are in the Initiative vs. Guilt stage.
During this time, they begin to assert power and control over the world through directing
play and other social interactions. Success in this stage leads to a sense of purpose, while
failure results in a sense of guilt.
3. A mother is concerned that her 6-month-old infant is not yet sitting unsupported. How
should the nurse respond?
A. Most infants begin to sit unsupported between 6 and 8 months.
B. Sitting unsupported is expected by 8 months of age.
C. This is a significant delay requiring immediate referral.
D. The infant should have achieved this milestone at 4 months.
Answer: A
Rationale: Developmental milestones have a range of normal achievement. Most infants
typically sit alone without support by 8 months, but they begin to practice and lean
forward on their hands (tripod sit) around 6 months. Providing reassurance while
monitoring progress is the appropriate nursing response.
4. What is the most effective way to prevent the spread of infection in a newborn nursery?
A. Wearing a mask at all times
B. Keeping infants in separate isolettes
, C. Strict hand hygiene practices
D. Prohibiting all visitors
Answer: C
Rationale: Hand hygiene is the single most important measure to prevent the transmission
of pathogens in the healthcare setting. Nurses must wash their hands before and after
every patient contact. This is especially critical in the newborn population due to their
immature immune systems.
5. Which of the following is an expected physical finding in a healthy 2-day-old newborn?
A. Posterior fontanelle closure
B. Regurgitation of all feedings
C. Positive Babinski reflex
D. Heart rate of 80 beats per minute
Answer: C
Rationale: The Babinski reflex is a normal finding in newborns and infants up to age 2. It
involves the fanning out of the toes when the sole of the foot is stroked. Other options like a
heart rate of 80 or constant regurgitation would be considered abnormal.
6. A postpartum client reports sharp calf pain that increases with dorsiflexion. What should
the nurse suspect?
A. Normal postpartum muscle soreness
