NUR166/NUR 166 Exam 4 V3 | Concepts of
Family Centered Nursing for the Practical
Nurse Q&A with Rationale | Hondros
College of Nursing
1. A nurse is caring for a patient who is at 34 weeks of gestation and has been diagnosed with
mild preeclampsia. Which of the following instructions should the nurse include in the
teaching plan?
A. Increase daily caffeine intake to improve renal perfusion.
B. Maintain a strictly low-protein diet until delivery.
C. Monitor fetal movement counts daily and report any significant decrease.
D. Perform vigorous aerobic exercise for 30 minutes daily.
Correct Answer: C
Rationale: Daily fetal movement monitoring is critical to assess fetal well-being in
pregnancies complicated by preeclampsia. The patient should be taught to recognize a
decrease in activity as a sign of potential fetal distress. Frequent rest and monitoring of
blood pressure are also standard components of home management for mild cases.
2. Which of the following signs observed in a newborn 2 hours after birth should the nurse
report to the provider as a potential complication?
A. Acrocyanosis of the hands and feet.
,B. Generalized petechiae over the entire body.
C. Milia across the bridge of the nose.
D. A respiratory rate of 45 breaths per minute.
Correct Answer: B
Rationale: Generalized petechiae can indicate a systemic infection or a clotting disorder in
the neonate. While acrocyanosis is a normal finding in the first 24 to 48 hours, petechiae
that are not localized to the presenting part require immediate investigation. The nurse
must differentiate between normal physiological transitions and pathological symptoms.
3. A nurse is providing discharge instructions to the parents of a toddler who has a new
diagnosis of iron deficiency anemia. Which dietary recommendation is most appropriate?
A. Provide large amounts of apple juice between meals.
B. Limit the child’s milk intake to 24 ounces per day.
C. Avoid giving the child green leafy vegetables.
D. Administer iron supplements with a large glass of milk.
Correct Answer: B
Rationale: Excessive intake of cow’s milk is a leading cause of iron deficiency anemia in
toddlers because it displaces iron-rich foods. Milk is low in iron and can also interfere with
the absorption of iron from other sources. Parents should be encouraged to offer a variety
of iron-fortified cereals and meats to meet nutritional needs.
, 4. When assessing a 4-year-old child, the nurse notes the child prefers to play alongside other
children rather than directly with them. How should the nurse document this behavior?
A. Solitary play
B. Associative play
C. Cooperative play
D. Parallel play
Correct Answer: D
Rationale: Parallel play is characterized by children playing independently but in close
proximity to others. This type of play is typical for toddlers and may still be seen in early
preschool years. Understanding developmental milestones helps the nurse assess if the
child is meeting age-appropriate social goals.
5. A patient at 38 weeks of gestation reports a sudden gush of clear fluid from the vagina.
Which action should the nurse take first?
A. Check the fetal heart rate (FHR).
B. Perform a sterile vaginal exam to check for dilation.
C. Notify the physician immediately.
D. Apply a clean perineal pad and check it in an hour.
Correct Answer: A
Family Centered Nursing for the Practical
Nurse Q&A with Rationale | Hondros
College of Nursing
1. A nurse is caring for a patient who is at 34 weeks of gestation and has been diagnosed with
mild preeclampsia. Which of the following instructions should the nurse include in the
teaching plan?
A. Increase daily caffeine intake to improve renal perfusion.
B. Maintain a strictly low-protein diet until delivery.
C. Monitor fetal movement counts daily and report any significant decrease.
D. Perform vigorous aerobic exercise for 30 minutes daily.
Correct Answer: C
Rationale: Daily fetal movement monitoring is critical to assess fetal well-being in
pregnancies complicated by preeclampsia. The patient should be taught to recognize a
decrease in activity as a sign of potential fetal distress. Frequent rest and monitoring of
blood pressure are also standard components of home management for mild cases.
2. Which of the following signs observed in a newborn 2 hours after birth should the nurse
report to the provider as a potential complication?
A. Acrocyanosis of the hands and feet.
,B. Generalized petechiae over the entire body.
C. Milia across the bridge of the nose.
D. A respiratory rate of 45 breaths per minute.
Correct Answer: B
Rationale: Generalized petechiae can indicate a systemic infection or a clotting disorder in
the neonate. While acrocyanosis is a normal finding in the first 24 to 48 hours, petechiae
that are not localized to the presenting part require immediate investigation. The nurse
must differentiate between normal physiological transitions and pathological symptoms.
3. A nurse is providing discharge instructions to the parents of a toddler who has a new
diagnosis of iron deficiency anemia. Which dietary recommendation is most appropriate?
A. Provide large amounts of apple juice between meals.
B. Limit the child’s milk intake to 24 ounces per day.
C. Avoid giving the child green leafy vegetables.
D. Administer iron supplements with a large glass of milk.
Correct Answer: B
Rationale: Excessive intake of cow’s milk is a leading cause of iron deficiency anemia in
toddlers because it displaces iron-rich foods. Milk is low in iron and can also interfere with
the absorption of iron from other sources. Parents should be encouraged to offer a variety
of iron-fortified cereals and meats to meet nutritional needs.
, 4. When assessing a 4-year-old child, the nurse notes the child prefers to play alongside other
children rather than directly with them. How should the nurse document this behavior?
A. Solitary play
B. Associative play
C. Cooperative play
D. Parallel play
Correct Answer: D
Rationale: Parallel play is characterized by children playing independently but in close
proximity to others. This type of play is typical for toddlers and may still be seen in early
preschool years. Understanding developmental milestones helps the nurse assess if the
child is meeting age-appropriate social goals.
5. A patient at 38 weeks of gestation reports a sudden gush of clear fluid from the vagina.
Which action should the nurse take first?
A. Check the fetal heart rate (FHR).
B. Perform a sterile vaginal exam to check for dilation.
C. Notify the physician immediately.
D. Apply a clean perineal pad and check it in an hour.
Correct Answer: A
