NUR231 Final Exam V2 | NUR 231
Childbearing & Child Caring Family Exam
Q&A | Galen College of Nursing
1. A nurse is caring for a client who is at 34 weeks of gestation and has a prescription for
magnesium sulfate. Which of the following findings indicates magnesium sulfate toxicity?
A. Respirations of 10 breaths per minute
B. Hyperreflexive deep tendon reflexes
C. Increased urinary output
D. Fetal heart rate of 140 beats per minute
Answer: A
Rationale: Respiratory depression below 12 breaths per minute is a hallmark sign of
magnesium sulfate toxicity. The nurse must monitor for decreased deep tendon reflexes
and oliguria as well. Calcium gluconate should be kept readily available as the antidote for
this condition.
2. A nurse is assessing a newborn who is 2 hours old. Which of the following findings should
the nurse report to the provider?
A. Acrocyanosis
B. Substernal retractions
C. Milia on the nose
,D. Heart rate of 150/min
Answer: B
Rationale: Substernal retractions are a sign of respiratory distress syndrome in a
newborn. Acrocyanosis and milia are considered normal physiological findings in the early
neonatal period. A heart rate of 150/min is within the expected reference range of 110 to
160/min for a newborn.
3. A client in the active phase of labor has a sudden gush of dark red blood and a board-like
abdomen. What is the priority nursing action?
A. Perform a vaginal exam to check for dilation
B. Assess maternal blood pressure and fetal heart rate
C. Encourage the client to use breathing techniques
D. Administer oxytocin to speed up labor
Answer: B
Rationale: A board-like abdomen and dark red bleeding indicate Abruptio Placentae,
which is a medical emergency. The nurse must prioritize assessing fetal and maternal
stability to determine the urgency of intervention. Immediate surgical delivery may be
required if the fetus or mother is compromised.
4. Which developmental stage, according to Erikson, applies to a 4-year-old child admitted for
surgery?
A. Trust vs. Mistrust
, B. Autonomy vs. Shame and Doubt
C. Industry vs. Inferiority
D. Initiative vs. Guilt
Answer: D
Rationale: Preschoolers aged 3 to 6 years are in the stage of Initiative vs. Guilt. During this
stage, children explore their environment and develop a sense of purpose. Illness or
hospitalization can make them feel that they are being punished for their thoughts or
actions.
5. A toddler is diagnosed with Iron Deficiency Anemia. Which dietary advice should the nurse
provide to the parents?
A. Limit milk intake to no more than 24 ounces per day
B. Provide at least 2 liters of water daily
C. Increase intake of dairy products to boost calcium
D. Give iron supplements with a large glass of milk
Answer: A
Rationale: Excessive milk consumption (milk anemia) is a common cause of iron
deficiency in toddlers because milk is low in iron and can displace iron-rich foods. Milk also
interferes with the absorption of iron if taken simultaneously with supplements. The nurse
should recommend vitamin C-rich foods to enhance iron absorption.
Childbearing & Child Caring Family Exam
Q&A | Galen College of Nursing
1. A nurse is caring for a client who is at 34 weeks of gestation and has a prescription for
magnesium sulfate. Which of the following findings indicates magnesium sulfate toxicity?
A. Respirations of 10 breaths per minute
B. Hyperreflexive deep tendon reflexes
C. Increased urinary output
D. Fetal heart rate of 140 beats per minute
Answer: A
Rationale: Respiratory depression below 12 breaths per minute is a hallmark sign of
magnesium sulfate toxicity. The nurse must monitor for decreased deep tendon reflexes
and oliguria as well. Calcium gluconate should be kept readily available as the antidote for
this condition.
2. A nurse is assessing a newborn who is 2 hours old. Which of the following findings should
the nurse report to the provider?
A. Acrocyanosis
B. Substernal retractions
C. Milia on the nose
,D. Heart rate of 150/min
Answer: B
Rationale: Substernal retractions are a sign of respiratory distress syndrome in a
newborn. Acrocyanosis and milia are considered normal physiological findings in the early
neonatal period. A heart rate of 150/min is within the expected reference range of 110 to
160/min for a newborn.
3. A client in the active phase of labor has a sudden gush of dark red blood and a board-like
abdomen. What is the priority nursing action?
A. Perform a vaginal exam to check for dilation
B. Assess maternal blood pressure and fetal heart rate
C. Encourage the client to use breathing techniques
D. Administer oxytocin to speed up labor
Answer: B
Rationale: A board-like abdomen and dark red bleeding indicate Abruptio Placentae,
which is a medical emergency. The nurse must prioritize assessing fetal and maternal
stability to determine the urgency of intervention. Immediate surgical delivery may be
required if the fetus or mother is compromised.
4. Which developmental stage, according to Erikson, applies to a 4-year-old child admitted for
surgery?
A. Trust vs. Mistrust
, B. Autonomy vs. Shame and Doubt
C. Industry vs. Inferiority
D. Initiative vs. Guilt
Answer: D
Rationale: Preschoolers aged 3 to 6 years are in the stage of Initiative vs. Guilt. During this
stage, children explore their environment and develop a sense of purpose. Illness or
hospitalization can make them feel that they are being punished for their thoughts or
actions.
5. A toddler is diagnosed with Iron Deficiency Anemia. Which dietary advice should the nurse
provide to the parents?
A. Limit milk intake to no more than 24 ounces per day
B. Provide at least 2 liters of water daily
C. Increase intake of dairy products to boost calcium
D. Give iron supplements with a large glass of milk
Answer: A
Rationale: Excessive milk consumption (milk anemia) is a common cause of iron
deficiency in toddlers because milk is low in iron and can displace iron-rich foods. Milk also
interferes with the absorption of iron if taken simultaneously with supplements. The nurse
should recommend vitamin C-rich foods to enhance iron absorption.
