NUR 418 / NUR 415 Exam 3 V1 | NUR 418 /
NUR 415 Nursing Care of the Childbearing
& Childrearing Family | Actual Q&A with
Rationale (NUR418/NUR415 Exam 3) |
Concordia
1. A nurse is caring for a client receiving intravenous magnesium sulfate for the treatment of
severe preeclampsia. Which of the following findings should the nurse identify as a priority to
report to the provider?
A. Urinary output of 40 mL per hour
B. Respiratory rate of 14 breaths per minute
C. Client report of feeling warm and flushed
D. Absent deep tendon reflexes
Correct Answer: D
Explanation; The loss of deep tendon reflexes is an early sign of magnesium sulfate
toxicity and must be reported immediately to prevent respiratory arrest. Magnesium
sulfate is a central nervous system depressant, and its toxicity can lead to severe
complications including cardiac arrest. The nurse should also ensure that calcium
gluconate is readily available as the reversal agent.
,2. A nurse is assessing a newborn 1 hour after birth. Which of the following findings should
the nurse identify as a manifestation of respiratory distress? (Select all that apply)
A. Nasal flaring
B. Expiratory grunting
C. Intercostal retractions
D. Acrocyanosis
E. Respiratory rate of 50 breaths per minute
F. Chin tugging
Correct Answer: A, B, C, F
Explanation; Nasal flaring, grunting, and retractions are classic signs of increased work of
breathing in a neonate. Chin tugging is also a sign of severe respiratory distress indicating
the use of accessory muscles. Acrocyanosis is a normal finding in the first 24 to 48 hours of
life, and a respiratory rate of 50 is within the expected range of 30 to 60 per minute.
3. A nurse is planning care for a child who has been admitted with a diagnosis of Tetralogy of
Fallot. The nurse should anticipate that the child will exhibit which of the following clinical
manifestations?
A. Bounding peripheral pulses
B. Decreased hematocrit levels
C. Clubbing of the fingers
,D. Hypotension in the lower extremities
Correct Answer: C
Explanation; Clubbing of the fingers occurs in children with Tetralogy of Fallot due to
chronic tissue hypoxia and polycythemia. Polycythemia is the body’s attempt to
compensate for low oxygen levels by producing more red blood cells. Bounding pulses are
more characteristic of Patent Ductus Arteriosus, not Tetralogy of Fallot.
4. A nurse is providing discharge teaching to the parents of a child who had a cleft palate
repair. Which of the following instructions should the nurse include?
A. Use a straw for liquids to prevent spilling.
B. Clean the suture line with a firm scrubbing motion.
C. Apply elbow restraints to the child.
D. Offer hard cookies to encourage chewing.
Correct Answer: C
Explanation; Elbow restraints are used to prevent the child from placing fingers or objects
in the mouth that could damage the surgical site. This protection is vital during the
immediate postoperative healing phase to ensure the integrity of the repair. The parents
should be taught to remove the restraints periodically under supervision to check the skin
and provide range of motion.
, 5. A nurse is assessing a postpartum client who is 4 hours following a vaginal delivery. Which
of the following findings should the nurse identify as the priority?
A. Fundus 2 cm above the umbilicus and deviated to the right
B. Moderate lochia rubra
C. Report of intense thirst
D. Uterine cramping during breastfeeding
Correct Answer: A
Explanation; A fundus that is high and deviated to the right suggests a distended bladder,
which can interfere with uterine contractions and lead to postpartum hemorrhage. The
nurse’s priority action is to assist the client to void to allow the uterus to contract
effectively. Moderate lochia rubra and afterpains during breastfeeding are expected
findings in the early postpartum period.
6. A nurse is caring for a 6-month-old infant who is postoperative following a
pyloromyotomy. Which of the following feeding schedules should the nurse anticipate?
A. Begin small, frequent feedings of electrolyte solution 4 to 6 hours postoperatively.
B. Keep the infant NPO for 48 hours.
C. Start full-strength formula immediately upon arrival to the floor.
D. Feed the infant only when they show signs of intense hunger.
Correct Answer: A
NUR 415 Nursing Care of the Childbearing
& Childrearing Family | Actual Q&A with
Rationale (NUR418/NUR415 Exam 3) |
Concordia
1. A nurse is caring for a client receiving intravenous magnesium sulfate for the treatment of
severe preeclampsia. Which of the following findings should the nurse identify as a priority to
report to the provider?
A. Urinary output of 40 mL per hour
B. Respiratory rate of 14 breaths per minute
C. Client report of feeling warm and flushed
D. Absent deep tendon reflexes
Correct Answer: D
Explanation; The loss of deep tendon reflexes is an early sign of magnesium sulfate
toxicity and must be reported immediately to prevent respiratory arrest. Magnesium
sulfate is a central nervous system depressant, and its toxicity can lead to severe
complications including cardiac arrest. The nurse should also ensure that calcium
gluconate is readily available as the reversal agent.
,2. A nurse is assessing a newborn 1 hour after birth. Which of the following findings should
the nurse identify as a manifestation of respiratory distress? (Select all that apply)
A. Nasal flaring
B. Expiratory grunting
C. Intercostal retractions
D. Acrocyanosis
E. Respiratory rate of 50 breaths per minute
F. Chin tugging
Correct Answer: A, B, C, F
Explanation; Nasal flaring, grunting, and retractions are classic signs of increased work of
breathing in a neonate. Chin tugging is also a sign of severe respiratory distress indicating
the use of accessory muscles. Acrocyanosis is a normal finding in the first 24 to 48 hours of
life, and a respiratory rate of 50 is within the expected range of 30 to 60 per minute.
3. A nurse is planning care for a child who has been admitted with a diagnosis of Tetralogy of
Fallot. The nurse should anticipate that the child will exhibit which of the following clinical
manifestations?
A. Bounding peripheral pulses
B. Decreased hematocrit levels
C. Clubbing of the fingers
,D. Hypotension in the lower extremities
Correct Answer: C
Explanation; Clubbing of the fingers occurs in children with Tetralogy of Fallot due to
chronic tissue hypoxia and polycythemia. Polycythemia is the body’s attempt to
compensate for low oxygen levels by producing more red blood cells. Bounding pulses are
more characteristic of Patent Ductus Arteriosus, not Tetralogy of Fallot.
4. A nurse is providing discharge teaching to the parents of a child who had a cleft palate
repair. Which of the following instructions should the nurse include?
A. Use a straw for liquids to prevent spilling.
B. Clean the suture line with a firm scrubbing motion.
C. Apply elbow restraints to the child.
D. Offer hard cookies to encourage chewing.
Correct Answer: C
Explanation; Elbow restraints are used to prevent the child from placing fingers or objects
in the mouth that could damage the surgical site. This protection is vital during the
immediate postoperative healing phase to ensure the integrity of the repair. The parents
should be taught to remove the restraints periodically under supervision to check the skin
and provide range of motion.
, 5. A nurse is assessing a postpartum client who is 4 hours following a vaginal delivery. Which
of the following findings should the nurse identify as the priority?
A. Fundus 2 cm above the umbilicus and deviated to the right
B. Moderate lochia rubra
C. Report of intense thirst
D. Uterine cramping during breastfeeding
Correct Answer: A
Explanation; A fundus that is high and deviated to the right suggests a distended bladder,
which can interfere with uterine contractions and lead to postpartum hemorrhage. The
nurse’s priority action is to assist the client to void to allow the uterus to contract
effectively. Moderate lochia rubra and afterpains during breastfeeding are expected
findings in the early postpartum period.
6. A nurse is caring for a 6-month-old infant who is postoperative following a
pyloromyotomy. Which of the following feeding schedules should the nurse anticipate?
A. Begin small, frequent feedings of electrolyte solution 4 to 6 hours postoperatively.
B. Keep the infant NPO for 48 hours.
C. Start full-strength formula immediately upon arrival to the floor.
D. Feed the infant only when they show signs of intense hunger.
Correct Answer: A
