NUR 418 / NUR 415 Exam 3 V2 | 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 magnesium sulfate for preeclampsia. Which of the
following findings should the nurse identify as an indication of magnesium toxicity?
A. Urinary output of 40 mL/hr
B. Blood pressure of 150/96 mmHg
C. Deep tendon reflexes (DTR) of 0
D. Respiratory rate of 14 breaths per minute
Correct Answer: C
Explanation; A loss of deep tendon reflexes is a primary sign of magnesium sulfate toxicity.
Magnesium sulfate acts as a central nervous system depressant and can lead to respiratory
depression if levels are too high. The nurse must monitor for these signs and be prepared
to administer calcium gluconate as an antidote.
2. A nurse is assessing a client at 34 weeks of gestation who presents with painless, bright red
vaginal bleeding. Which of the following conditions should the nurse suspect?
A. Abruptio placentae
,B. Placenta previa
C. Uterine rupture
D. Vasa previa
Correct Answer: B
Explanation; Placenta previa is characterized by the sudden onset of painless, bright red
vaginal bleeding in the third trimester. This occurs when the placenta covers the internal
cervical os. In contrast, abruptio placentae typically presents with painful bleeding and a
rigid abdomen.
3. Which of the following interventions should a nurse implement for a newborn receiving
phototherapy for hyperbilirubinemia? (Select All That Apply)
A. Apply lotion to the newborn’s skin to prevent drying.
B. Cover the newborn’s eyes with an opaque mask.
C. Keep the newborn in a diaper only.
D. Monitor intake and output to assess for dehydration.
E. Reposition the newborn every 2 to 3 hours.
F. Discontinue breastfeeding to limit fluid volume.
Correct Answer: B, C, D, E
Explanation; Phototherapy requires maximum skin exposure, so keeping the newborn in
only a diaper is essential. Protective eye masks are used to prevent retinal damage from the
,blue-light spectrum. Regular repositioning ensures all skin surfaces are exposed, and
monitoring hydration is critical due to increased insensible water loss under the lights.
4. A nurse is preparing to administer methylergonovine to a client who is experiencing
postpartum hemorrhage. Which of the following findings is a contraindication for this
medication?
A. Tachycardia
B. Asthma
C. Hypertension
D. Hypomagnesemia
Correct Answer: C
Explanation; Methylergonovine is an oxytocic medication that can cause significant
vasoconstriction and elevation in blood pressure. It is strictly contraindicated in patients
with pre-existing hypertension or gestational hypertension. The nurse should check the
client’s blood pressure prior to administration to ensure it is within safe limits.
5. A school-age child is admitted with a suspected diagnosis of acute appendicitis. Which of
the following physical assessment findings should the nurse expect?
A. Rebound tenderness at McBurney’s point
B. Steatorrhea
C. Pain localized in the left lower quadrant
, D. Projectile vomiting
Correct Answer: A
Explanation; Appendicitis typically presents with pain that migrates to the right lower
quadrant, specifically at McBurney’s point. Rebound tenderness is a classic sign of
peritoneal irritation associated with the appendix. Sudden relief of pain may indicate that
the appendix has ruptured, which is a medical emergency.
6. A nurse is teaching a parent of a child with Celiac disease. Which of the following food
choices should the nurse recommend?
A. Rice cakes
B. Barley soup
C. Wheat crackers
D. Rye bread
Correct Answer: A
Explanation; Celiac disease is an immune reaction to eating gluten, which is found in
wheat, barley, and rye. Rice is a gluten-free grain and is safe for consumption by individuals
with this condition. Education should focus on reading labels carefully for hidden sources
of gluten in processed foods.
7. Which of the following signs are indicative of respiratory distress in a newborn? (Select All
That Apply)
A. Nasal flaring
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 magnesium sulfate for preeclampsia. Which of the
following findings should the nurse identify as an indication of magnesium toxicity?
A. Urinary output of 40 mL/hr
B. Blood pressure of 150/96 mmHg
C. Deep tendon reflexes (DTR) of 0
D. Respiratory rate of 14 breaths per minute
Correct Answer: C
Explanation; A loss of deep tendon reflexes is a primary sign of magnesium sulfate toxicity.
Magnesium sulfate acts as a central nervous system depressant and can lead to respiratory
depression if levels are too high. The nurse must monitor for these signs and be prepared
to administer calcium gluconate as an antidote.
2. A nurse is assessing a client at 34 weeks of gestation who presents with painless, bright red
vaginal bleeding. Which of the following conditions should the nurse suspect?
A. Abruptio placentae
,B. Placenta previa
C. Uterine rupture
D. Vasa previa
Correct Answer: B
Explanation; Placenta previa is characterized by the sudden onset of painless, bright red
vaginal bleeding in the third trimester. This occurs when the placenta covers the internal
cervical os. In contrast, abruptio placentae typically presents with painful bleeding and a
rigid abdomen.
3. Which of the following interventions should a nurse implement for a newborn receiving
phototherapy for hyperbilirubinemia? (Select All That Apply)
A. Apply lotion to the newborn’s skin to prevent drying.
B. Cover the newborn’s eyes with an opaque mask.
C. Keep the newborn in a diaper only.
D. Monitor intake and output to assess for dehydration.
E. Reposition the newborn every 2 to 3 hours.
F. Discontinue breastfeeding to limit fluid volume.
Correct Answer: B, C, D, E
Explanation; Phototherapy requires maximum skin exposure, so keeping the newborn in
only a diaper is essential. Protective eye masks are used to prevent retinal damage from the
,blue-light spectrum. Regular repositioning ensures all skin surfaces are exposed, and
monitoring hydration is critical due to increased insensible water loss under the lights.
4. A nurse is preparing to administer methylergonovine to a client who is experiencing
postpartum hemorrhage. Which of the following findings is a contraindication for this
medication?
A. Tachycardia
B. Asthma
C. Hypertension
D. Hypomagnesemia
Correct Answer: C
Explanation; Methylergonovine is an oxytocic medication that can cause significant
vasoconstriction and elevation in blood pressure. It is strictly contraindicated in patients
with pre-existing hypertension or gestational hypertension. The nurse should check the
client’s blood pressure prior to administration to ensure it is within safe limits.
5. A school-age child is admitted with a suspected diagnosis of acute appendicitis. Which of
the following physical assessment findings should the nurse expect?
A. Rebound tenderness at McBurney’s point
B. Steatorrhea
C. Pain localized in the left lower quadrant
, D. Projectile vomiting
Correct Answer: A
Explanation; Appendicitis typically presents with pain that migrates to the right lower
quadrant, specifically at McBurney’s point. Rebound tenderness is a classic sign of
peritoneal irritation associated with the appendix. Sudden relief of pain may indicate that
the appendix has ruptured, which is a medical emergency.
6. A nurse is teaching a parent of a child with Celiac disease. Which of the following food
choices should the nurse recommend?
A. Rice cakes
B. Barley soup
C. Wheat crackers
D. Rye bread
Correct Answer: A
Explanation; Celiac disease is an immune reaction to eating gluten, which is found in
wheat, barley, and rye. Rice is a gluten-free grain and is safe for consumption by individuals
with this condition. Education should focus on reading labels carefully for hidden sources
of gluten in processed foods.
7. Which of the following signs are indicative of respiratory distress in a newborn? (Select All
That Apply)
A. Nasal flaring
