NUR231 Exam 3 V3 | NUR 231
Childbearing & Child Caring Family Exam
Q&A | Galen College of Nursing
1. A nurse is caring for a newborn immediately after birth. Which action should the nurse
prioritize to prevent heat loss through evaporation?
A. Dry the newborn thoroughly with a warm towel
B. Place the newborn on a pre-warmed radiant warmer
C. Move the crib away from windows and air vents
D. Place the newborn in skin-to-skin contact with the mother
Answer: A
Rationale: Evaporation occurs when moisture on the skin is converted to vapor. Drying
the infant immediately after birth is the most effective way to prevent this specific type of
heat loss. Conduction is prevented by warm surfaces, and radiation is prevented by
avoiding cold walls or windows.
2. A newborn has a heart rate of 110 bpm, a weak cry, some flexion of the extremities,
grimaces when flicked on the sole of the foot, and a pink body with blue extremities. What is
the APGAR score?
A. 5
B. 7
,C. 6
D. 8
Answer: C
Rationale: Heart rate > 100 (2 points), Weak cry (1 point), Some flexion (1 point), Grimace
(1 point), Acrocyanosis (1 point). 2+1+1+1+1 = 6 points.
3. Which nursing intervention is essential for a newborn receiving phototherapy for
hyperbilirubinemia?
A. Apply lotion to the skin to prevent drying
B. Cover the infant’s eyes with opaque shields
C. Keep the infant dressed in a diaper and t-shirt
D. Limit fluid intake to prevent diarrhea
Answer: B
Rationale: The infant’s eyes must be protected from the high-intensity light used in
phototherapy to prevent retinal damage. Lotions should be avoided as they can cause
burns, and maximum skin exposure (only a diaper) is required for treatment efficacy.
4. When assessing a 2-month-old infant, the nurse notes the anterior fontanel is flat and soft.
How should the nurse interpret this finding?
A. It is a sign of increased intracranial pressure
B. It is a normal assessment finding
, C. It indicates the infant is severely dehydrated
D. It suggests premature closure of the cranial sutures
Answer: B
Rationale: A soft, flat anterior fontanel is a normal finding in an infant. A bulging fontanel
suggests increased intracranial pressure, while a sunken fontanel suggests dehydration.
5. An infant weighs 8 kg and is prescribed a medication at 15 mg/kg/dose. What is the correct
dose the nurse should administer?
A. 100 mg
B. 150 mg
C. 120 mg
D. 200 mg
Answer: C
Rationale: The calculation is 8 kg multiplied by 15 mg/kg, which equals 120 mg.
6. Which developmental milestone is typically achieved by a 6-month-old infant?
A. Walking while holding onto furniture
B. Rolling from back to abdomen
C. Using a pincer grasp to pick up small objects
D. Sitting alone without support
Childbearing & Child Caring Family Exam
Q&A | Galen College of Nursing
1. A nurse is caring for a newborn immediately after birth. Which action should the nurse
prioritize to prevent heat loss through evaporation?
A. Dry the newborn thoroughly with a warm towel
B. Place the newborn on a pre-warmed radiant warmer
C. Move the crib away from windows and air vents
D. Place the newborn in skin-to-skin contact with the mother
Answer: A
Rationale: Evaporation occurs when moisture on the skin is converted to vapor. Drying
the infant immediately after birth is the most effective way to prevent this specific type of
heat loss. Conduction is prevented by warm surfaces, and radiation is prevented by
avoiding cold walls or windows.
2. A newborn has a heart rate of 110 bpm, a weak cry, some flexion of the extremities,
grimaces when flicked on the sole of the foot, and a pink body with blue extremities. What is
the APGAR score?
A. 5
B. 7
,C. 6
D. 8
Answer: C
Rationale: Heart rate > 100 (2 points), Weak cry (1 point), Some flexion (1 point), Grimace
(1 point), Acrocyanosis (1 point). 2+1+1+1+1 = 6 points.
3. Which nursing intervention is essential for a newborn receiving phototherapy for
hyperbilirubinemia?
A. Apply lotion to the skin to prevent drying
B. Cover the infant’s eyes with opaque shields
C. Keep the infant dressed in a diaper and t-shirt
D. Limit fluid intake to prevent diarrhea
Answer: B
Rationale: The infant’s eyes must be protected from the high-intensity light used in
phototherapy to prevent retinal damage. Lotions should be avoided as they can cause
burns, and maximum skin exposure (only a diaper) is required for treatment efficacy.
4. When assessing a 2-month-old infant, the nurse notes the anterior fontanel is flat and soft.
How should the nurse interpret this finding?
A. It is a sign of increased intracranial pressure
B. It is a normal assessment finding
, C. It indicates the infant is severely dehydrated
D. It suggests premature closure of the cranial sutures
Answer: B
Rationale: A soft, flat anterior fontanel is a normal finding in an infant. A bulging fontanel
suggests increased intracranial pressure, while a sunken fontanel suggests dehydration.
5. An infant weighs 8 kg and is prescribed a medication at 15 mg/kg/dose. What is the correct
dose the nurse should administer?
A. 100 mg
B. 150 mg
C. 120 mg
D. 200 mg
Answer: C
Rationale: The calculation is 8 kg multiplied by 15 mg/kg, which equals 120 mg.
6. Which developmental milestone is typically achieved by a 6-month-old infant?
A. Walking while holding onto furniture
B. Rolling from back to abdomen
C. Using a pincer grasp to pick up small objects
D. Sitting alone without support
