NUR 418 / NUR 415 Exam 3 V3 | 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 who is at 34 weeks gestation and has a prescription for
magnesium sulfate IV to treat severe preeclampsia. Which of the following findings should
the nurse identify as an indication of magnesium toxicity?
A. Deep tendon reflexes +2
B. Respiratory rate of 10/min
C. Urine output of 40 mL/hr
D. Serum magnesium level of 6 mg/dL
Correct Answer: B
Explanation; Magnesium sulfate is a central nervous system depressant used to prevent
seizures in preeclampsia. A respiratory rate of less than 12/min is a primary indicator of
magnesium toxicity and requires immediate intervention. The nurse should also monitor
for the loss of deep tendon reflexes and a significant drop in urine output.
2. A nurse is assessing a newborn 1 hour after birth. Which of the following findings should
the nurse report to the provider?
A. Jitteriness or tremors
,B. Acrocyanosis
C. Milia on the bridge of the nose
D. Heart rate of 140/min
Correct Answer: A
Explanation; Jitteriness in a newborn can be a sign of hypoglycemia or neonatal
abstinence syndrome and requires further investigation of blood glucose levels.
Acrocyanosis is a normal finding in the first 24 to 48 hours of life due to poor peripheral
circulation. Milia are common sebaceous gland secretions that resolve spontaneously
without treatment.
3. A nurse is providing teaching to the parents of an infant who has a new diagnosis of pyloric
stenosis. Which of the following clinical manifestations should the nurse include in the
teaching?
A. Steatorrhea
B. Projectile vomiting
C. Ribbon-like stools
D. Currant jelly-like stools
Correct Answer: B
Explanation; Pyloric stenosis is characterized by the thickening of the pyloric sphincter,
which leads to gastric outlet obstruction. Projectile vomiting is the hallmark sign, occurring
,typically shortly after feedings and becoming more forceful over time. This condition
usually manifests within the first few weeks of life and requires surgical correction
(pyloromyotomy).
4. A nurse is caring for a client who is 2 hours postpartum. Which of the following actions
should the nurse take first when observing a large amount of lochia rubra and a boggy
uterus?
A. Administer oxytocin IV
B. Insert an indwelling urinary catheter
C. Massage the fundus
D. Notify the provider
Correct Answer: C
Explanation; The first action the nurse should take is to massage the fundus to stimulate
uterine contractions and resolve uterine atony. Uterine atony is the most common cause of
postpartum hemorrhage. If the fundus remains boggy after massage, then other
interventions like emptying the bladder or administering medications may be necessary.
5. A nurse is caring for an infant who has respiratory syncytial virus (RSV). Which of the
following infection control precautions should the nurse implement? (Select All That Apply)
A. Standard precautions
B. Contact precautions
C. Droplet precautions
, D. Airborne precautions
E. Negative pressure room
F. Protective environment
Correct Answer: ABC
Explanation; RSV is primarily transmitted through direct contact with secretions or
indirectly via contaminated surfaces, requiring contact precautions. Many facilities also
utilize droplet precautions because the virus can be spread via large respiratory droplets
during coughing or sneezing. Standard precautions are the baseline for all patient care to
prevent the spread of infections.
6. A nurse is assessing a child who has nephrotic syndrome. Which of the following findings
should the nurse expect?
A. Gross hematuria
B. Massive proteinuria
C. Decreased serum lipids
D. Hypotension
Correct Answer: B
Explanation; Nephrotic syndrome is characterized by increased glomerular permeability,
which leads to massive proteinuria. This loss of protein results in hypoalbuminemia and
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 who is at 34 weeks gestation and has a prescription for
magnesium sulfate IV to treat severe preeclampsia. Which of the following findings should
the nurse identify as an indication of magnesium toxicity?
A. Deep tendon reflexes +2
B. Respiratory rate of 10/min
C. Urine output of 40 mL/hr
D. Serum magnesium level of 6 mg/dL
Correct Answer: B
Explanation; Magnesium sulfate is a central nervous system depressant used to prevent
seizures in preeclampsia. A respiratory rate of less than 12/min is a primary indicator of
magnesium toxicity and requires immediate intervention. The nurse should also monitor
for the loss of deep tendon reflexes and a significant drop in urine output.
2. A nurse is assessing a newborn 1 hour after birth. Which of the following findings should
the nurse report to the provider?
A. Jitteriness or tremors
,B. Acrocyanosis
C. Milia on the bridge of the nose
D. Heart rate of 140/min
Correct Answer: A
Explanation; Jitteriness in a newborn can be a sign of hypoglycemia or neonatal
abstinence syndrome and requires further investigation of blood glucose levels.
Acrocyanosis is a normal finding in the first 24 to 48 hours of life due to poor peripheral
circulation. Milia are common sebaceous gland secretions that resolve spontaneously
without treatment.
3. A nurse is providing teaching to the parents of an infant who has a new diagnosis of pyloric
stenosis. Which of the following clinical manifestations should the nurse include in the
teaching?
A. Steatorrhea
B. Projectile vomiting
C. Ribbon-like stools
D. Currant jelly-like stools
Correct Answer: B
Explanation; Pyloric stenosis is characterized by the thickening of the pyloric sphincter,
which leads to gastric outlet obstruction. Projectile vomiting is the hallmark sign, occurring
,typically shortly after feedings and becoming more forceful over time. This condition
usually manifests within the first few weeks of life and requires surgical correction
(pyloromyotomy).
4. A nurse is caring for a client who is 2 hours postpartum. Which of the following actions
should the nurse take first when observing a large amount of lochia rubra and a boggy
uterus?
A. Administer oxytocin IV
B. Insert an indwelling urinary catheter
C. Massage the fundus
D. Notify the provider
Correct Answer: C
Explanation; The first action the nurse should take is to massage the fundus to stimulate
uterine contractions and resolve uterine atony. Uterine atony is the most common cause of
postpartum hemorrhage. If the fundus remains boggy after massage, then other
interventions like emptying the bladder or administering medications may be necessary.
5. A nurse is caring for an infant who has respiratory syncytial virus (RSV). Which of the
following infection control precautions should the nurse implement? (Select All That Apply)
A. Standard precautions
B. Contact precautions
C. Droplet precautions
, D. Airborne precautions
E. Negative pressure room
F. Protective environment
Correct Answer: ABC
Explanation; RSV is primarily transmitted through direct contact with secretions or
indirectly via contaminated surfaces, requiring contact precautions. Many facilities also
utilize droplet precautions because the virus can be spread via large respiratory droplets
during coughing or sneezing. Standard precautions are the baseline for all patient care to
prevent the spread of infections.
6. A nurse is assessing a child who has nephrotic syndrome. Which of the following findings
should the nurse expect?
A. Gross hematuria
B. Massive proteinuria
C. Decreased serum lipids
D. Hypotension
Correct Answer: B
Explanation; Nephrotic syndrome is characterized by increased glomerular permeability,
which leads to massive proteinuria. This loss of protein results in hypoalbuminemia and
