NUR 418 / NUR 415 Exam 4 V1 | NUR 418 /
NUR 415 Nursing Care of the Childbearing
& Childrearing Family | Actual Q&A with
Rationale (NUR418/NUR415 Exam 4) |
Concordia
1. A nurse is monitoring a client who is receiving magnesium sulfate for severe preeclampsia.
Which assessment finding should the nurse report to the provider immediately?
A. Respiratory rate of 10 breaths/min
B. Urinary output of 40 mL/hr
C. Deep tendon reflexes of 2+
D. Blood pressure of 150/96 mmHg
Correct Answer: A
Explanation; A respiratory rate below 12 breaths per minute is a critical sign of
magnesium sulfate toxicity. The nurse must also monitor for absent deep tendon reflexes
and a significant drop in urinary output below 30 mL/hr. If toxicity occurs, the infusion
must be stopped and calcium gluconate should be prepared as the antagonist.
2. A nurse is teaching a parent of a child with cystic fibrosis about nutrition. Which instruction
should the nurse include in the teaching?
A. Administer pancreatic enzymes 2 hours after meals.
,B. Provide a high-calorie, high-protein diet.
C. Limit fluid intake to prevent mucus thickening.
D. Restrict salt intake during summer months.
Correct Answer: B
Explanation; Children with cystic fibrosis require a high-calorie, high-protein diet to
compensate for malabsorption issues. Pancreatic enzymes must be taken with every meal
and snack to facilitate the digestion of fats and proteins. Increased salt intake is actually
encouraged, especially in hot weather, to replace sodium lost through sweat.
3. Which of the following are clinical manifestations of Tetralogy of Fallot? (Select All That
Apply)
A. Ventricular septal defect
B. Pulmonary stenosis
C. Atrial septal defect
D. Overriding aorta
E. Right ventricular hypertrophy
Correct Answer: ABDE
Explanation; Tetralogy of Fallot consists of four specific heart defects: ventricular septal
defect, pulmonary stenosis, overriding aorta, and right ventricular hypertrophy. Atrial
septal defect is not part of this specific tetralogy, though it may occur in other complex
,heart conditions. Management often includes surgical repair and placing the infant in a
knee-chest position during cyanotic spells.
4. A nurse is assessing a newborn with Neonatal Abstinence Syndrome (NAS). Which clinical
finding should the nurse expect?
A. Excessive high-pitched crying
B. Hypotonia and lethargy
C. Bradycardia and bradypnea
D. Increased sleeping periods
Correct Answer: A
Explanation; Neonatal Abstinence Syndrome typically presents with central nervous
system irritability, including a high-pitched cry and tremors. Newborns often exhibit
hypertonicity and have difficulty with feeding and sleeping due to withdrawal symptoms.
Nursing care focuses on reducing environmental stimuli and providing small, frequent
feedings to support the infant.
5. A client at 34 weeks gestation presents with painless, bright red vaginal bleeding. Which
action should the nurse avoid?
A. Applying a pulse oximeter
B. Initiating external fetal monitoring
C. Obtaining a blood type and crossmatch
, D. Performing a sterile vaginal exam
Correct Answer: D
Explanation; Painless, bright red bleeding is a classic sign of placenta previa, and a vaginal
exam is strictly contraindicated as it can cause massive hemorrhage. The nurse should use
ultrasound to confirm placental placement before any vaginal instrumentation.
Maintenance of maternal hemodynamic stability and monitoring fetal well-being are the
primary goals of care.
6. Which intervention is the priority for an infant experiencing a hypercyanotic (‘tet’) spell?
A. Administering oral digoxin
B. Increasing intravenous fluid rate
C. Placing the infant in a knee-chest position
D. Administering high-flow oxygen via mask
Correct Answer: C
Explanation; The knee-chest position increases systemic vascular resistance, which helps
reduce the right-to-left shunt and improves oxygenation. While oxygen administration is
beneficial, the physical positioning of the infant is the immediate priority to reverse the
pathophysiology of the spell. Calmness and morphine administration may also be used to
reduce infundibular spasms.
NUR 415 Nursing Care of the Childbearing
& Childrearing Family | Actual Q&A with
Rationale (NUR418/NUR415 Exam 4) |
Concordia
1. A nurse is monitoring a client who is receiving magnesium sulfate for severe preeclampsia.
Which assessment finding should the nurse report to the provider immediately?
A. Respiratory rate of 10 breaths/min
B. Urinary output of 40 mL/hr
C. Deep tendon reflexes of 2+
D. Blood pressure of 150/96 mmHg
Correct Answer: A
Explanation; A respiratory rate below 12 breaths per minute is a critical sign of
magnesium sulfate toxicity. The nurse must also monitor for absent deep tendon reflexes
and a significant drop in urinary output below 30 mL/hr. If toxicity occurs, the infusion
must be stopped and calcium gluconate should be prepared as the antagonist.
2. A nurse is teaching a parent of a child with cystic fibrosis about nutrition. Which instruction
should the nurse include in the teaching?
A. Administer pancreatic enzymes 2 hours after meals.
,B. Provide a high-calorie, high-protein diet.
C. Limit fluid intake to prevent mucus thickening.
D. Restrict salt intake during summer months.
Correct Answer: B
Explanation; Children with cystic fibrosis require a high-calorie, high-protein diet to
compensate for malabsorption issues. Pancreatic enzymes must be taken with every meal
and snack to facilitate the digestion of fats and proteins. Increased salt intake is actually
encouraged, especially in hot weather, to replace sodium lost through sweat.
3. Which of the following are clinical manifestations of Tetralogy of Fallot? (Select All That
Apply)
A. Ventricular septal defect
B. Pulmonary stenosis
C. Atrial septal defect
D. Overriding aorta
E. Right ventricular hypertrophy
Correct Answer: ABDE
Explanation; Tetralogy of Fallot consists of four specific heart defects: ventricular septal
defect, pulmonary stenosis, overriding aorta, and right ventricular hypertrophy. Atrial
septal defect is not part of this specific tetralogy, though it may occur in other complex
,heart conditions. Management often includes surgical repair and placing the infant in a
knee-chest position during cyanotic spells.
4. A nurse is assessing a newborn with Neonatal Abstinence Syndrome (NAS). Which clinical
finding should the nurse expect?
A. Excessive high-pitched crying
B. Hypotonia and lethargy
C. Bradycardia and bradypnea
D. Increased sleeping periods
Correct Answer: A
Explanation; Neonatal Abstinence Syndrome typically presents with central nervous
system irritability, including a high-pitched cry and tremors. Newborns often exhibit
hypertonicity and have difficulty with feeding and sleeping due to withdrawal symptoms.
Nursing care focuses on reducing environmental stimuli and providing small, frequent
feedings to support the infant.
5. A client at 34 weeks gestation presents with painless, bright red vaginal bleeding. Which
action should the nurse avoid?
A. Applying a pulse oximeter
B. Initiating external fetal monitoring
C. Obtaining a blood type and crossmatch
, D. Performing a sterile vaginal exam
Correct Answer: D
Explanation; Painless, bright red bleeding is a classic sign of placenta previa, and a vaginal
exam is strictly contraindicated as it can cause massive hemorrhage. The nurse should use
ultrasound to confirm placental placement before any vaginal instrumentation.
Maintenance of maternal hemodynamic stability and monitoring fetal well-being are the
primary goals of care.
6. Which intervention is the priority for an infant experiencing a hypercyanotic (‘tet’) spell?
A. Administering oral digoxin
B. Increasing intravenous fluid rate
C. Placing the infant in a knee-chest position
D. Administering high-flow oxygen via mask
Correct Answer: C
Explanation; The knee-chest position increases systemic vascular resistance, which helps
reduce the right-to-left shunt and improves oxygenation. While oxygen administration is
beneficial, the physical positioning of the infant is the immediate priority to reverse the
pathophysiology of the spell. Calmness and morphine administration may also be used to
reduce infundibular spasms.
