NUR 230 Final Exam V1 | NUR 230 The
Childbearing / Child Caring Family | Q&A
with Rationale (NUR230 Final Exam) |
Galen College of Nursing
1. A nurse is caring for a client who is at 36 weeks of gestation and has a prescription for a
nonstress test (NST). Which of the following instructions should the nurse provide to the
client?
A. You will need to be NPO for 4 hours prior to the procedure.
B. You should drink a large amount of water to fill your bladder.
C. You will press a button when you feel the baby move.
D. You will receive a medication to stimulate contractions.
Answer: C
Rationale: A nonstress test is used to assess fetal well-being by monitoring the fetal heart
rate in response to fetal movement. The client is typically asked to press a handheld button
whenever they perceive fetal movement to mark the event on the tracing. This procedure is
non-invasive and does not require the client to be NPO or have a full bladder.
,2. A nurse is monitoring a client who is receiving magnesium sulfate via continuous IV
infusion for preeclampsia. Which of the following findings should the nurse identify as a sign
of magnesium toxicity?
A. Respiratory rate of 10/min
B. Hyperreflexia (3+ deep tendon reflexes)
C. Increased urine output
D. Tachycardia
Answer: A
Rationale: Magnesium sulfate toxicity is characterized by central nervous system
depression, which leads to decreased respirations and loss of deep tendon reflexes. A
respiratory rate below 12/min is a significant warning sign that the infusion must be
stopped. The nurse should also monitor for decreased urinary output, as the medication is
excreted by the kidneys.
3. A nurse is teaching a group of parents about the prevention of Sudden Infant Death
Syndrome (SIDS). Which of the following recommendations should the nurse include?
A. Place the infant in a side-lying position for sleep.
B. Allow the infant to sleep in the parents’ bed.
C. Keep the infant’s room temperature very warm.
D. Use a firm mattress with a fitted sheet in the crib.
,Answer: D
Rationale: The Safe to Sleep campaign recommends that infants be placed on a firm
mattress with a tight-fitting sheet to reduce the risk of SIDS. The infant should always be
placed on their back (supine) for every sleep period to maintain an open airway. Co-
sleeping and loose bedding are significant risk factors that must be avoided to ensure
infant safety.
4. A nurse is assessing a 4-year-old child during a well-child visit. Which of the following
findings should the nurse expect according to Erikson’s stages of psychosocial development?
A. The child shows a sense of guilt when they misbehave.
B. The child focuses on developing industry and competence.
C. The child is primarily concerned with establishing autonomy.
D. The child is developing a sense of trust in caregivers.
Answer: A
Rationale: According to Erikson, preschoolers (ages 3 to 6) are in the stage of Initiative
vs. Guilt. Children in this stage explore their environment and take on new activities, but
may feel guilt if their actions lead to conflict or disapproval. Helping children balance their
desire for independence with social boundaries is a key developmental task during this
period.
, 5. A client at 32 weeks of gestation presents with painless, bright red vaginal bleeding. Which
of the following actions should the nurse perform first?
A. Perform a sterile vaginal examination to check dilation.
B. Administer oxytocin to control the bleeding.
C. Apply a fetal monitor to assess the fetal heart rate.
D. Prepare the client for an immediate cesarean delivery.
Answer: C
Rationale: Painless bright red bleeding is a classic sign of placenta previa, and the priority
action is to assess the status of the fetus using a monitor. A vaginal examination is strictly
contraindicated as it can cause further placental separation and life-threatening
hemorrhage. The nurse must stabilize the client and notify the healthcare provider while
avoiding any digital pelvic exams.
6. A nurse is assessing a newborn 1 minute after birth and notes the following: heart rate
110/min, slow and weak cry, some flexion of extremities, grimace in response to suctioning,
and body pink with blue extremities. What is the Apgar score?
A. 5
B. 8
C. 7
D. 6
Childbearing / Child Caring Family | Q&A
with Rationale (NUR230 Final Exam) |
Galen College of Nursing
1. A nurse is caring for a client who is at 36 weeks of gestation and has a prescription for a
nonstress test (NST). Which of the following instructions should the nurse provide to the
client?
A. You will need to be NPO for 4 hours prior to the procedure.
B. You should drink a large amount of water to fill your bladder.
C. You will press a button when you feel the baby move.
D. You will receive a medication to stimulate contractions.
Answer: C
Rationale: A nonstress test is used to assess fetal well-being by monitoring the fetal heart
rate in response to fetal movement. The client is typically asked to press a handheld button
whenever they perceive fetal movement to mark the event on the tracing. This procedure is
non-invasive and does not require the client to be NPO or have a full bladder.
,2. A nurse is monitoring a client who is receiving magnesium sulfate via continuous IV
infusion for preeclampsia. Which of the following findings should the nurse identify as a sign
of magnesium toxicity?
A. Respiratory rate of 10/min
B. Hyperreflexia (3+ deep tendon reflexes)
C. Increased urine output
D. Tachycardia
Answer: A
Rationale: Magnesium sulfate toxicity is characterized by central nervous system
depression, which leads to decreased respirations and loss of deep tendon reflexes. A
respiratory rate below 12/min is a significant warning sign that the infusion must be
stopped. The nurse should also monitor for decreased urinary output, as the medication is
excreted by the kidneys.
3. A nurse is teaching a group of parents about the prevention of Sudden Infant Death
Syndrome (SIDS). Which of the following recommendations should the nurse include?
A. Place the infant in a side-lying position for sleep.
B. Allow the infant to sleep in the parents’ bed.
C. Keep the infant’s room temperature very warm.
D. Use a firm mattress with a fitted sheet in the crib.
,Answer: D
Rationale: The Safe to Sleep campaign recommends that infants be placed on a firm
mattress with a tight-fitting sheet to reduce the risk of SIDS. The infant should always be
placed on their back (supine) for every sleep period to maintain an open airway. Co-
sleeping and loose bedding are significant risk factors that must be avoided to ensure
infant safety.
4. A nurse is assessing a 4-year-old child during a well-child visit. Which of the following
findings should the nurse expect according to Erikson’s stages of psychosocial development?
A. The child shows a sense of guilt when they misbehave.
B. The child focuses on developing industry and competence.
C. The child is primarily concerned with establishing autonomy.
D. The child is developing a sense of trust in caregivers.
Answer: A
Rationale: According to Erikson, preschoolers (ages 3 to 6) are in the stage of Initiative
vs. Guilt. Children in this stage explore their environment and take on new activities, but
may feel guilt if their actions lead to conflict or disapproval. Helping children balance their
desire for independence with social boundaries is a key developmental task during this
period.
, 5. A client at 32 weeks of gestation presents with painless, bright red vaginal bleeding. Which
of the following actions should the nurse perform first?
A. Perform a sterile vaginal examination to check dilation.
B. Administer oxytocin to control the bleeding.
C. Apply a fetal monitor to assess the fetal heart rate.
D. Prepare the client for an immediate cesarean delivery.
Answer: C
Rationale: Painless bright red bleeding is a classic sign of placenta previa, and the priority
action is to assess the status of the fetus using a monitor. A vaginal examination is strictly
contraindicated as it can cause further placental separation and life-threatening
hemorrhage. The nurse must stabilize the client and notify the healthcare provider while
avoiding any digital pelvic exams.
6. A nurse is assessing a newborn 1 minute after birth and notes the following: heart rate
110/min, slow and weak cry, some flexion of extremities, grimace in response to suctioning,
and body pink with blue extremities. What is the Apgar score?
A. 5
B. 8
C. 7
D. 6
