BSN 366 CONCEPTS OF NURSING IV (PDF) | 2026 EXAM
QUESTIONS AND ANSWERS + RATIONALES | STUDY GUIDE |
100% CORRECT
1. The turtle sign (retraction of the fetal head against the perineum after delivery) indicates which
obstetric emergency?
A) Nuchal cord
B) Shoulder dystocia
C) Uterine rupture
D) Placental abruption
Correct Answer: B) Shoulder dystocia
Rationale: The "turtle sign" is the hallmark of shoulder dystocia, where the fetal shoulders are
impacted behind the maternal symphysis pubis. The nurse should immediately call for assistance
and prepare for maneuvers such as McRoberts' and suprapubic pressure .
2. A newborn is 12 hours old and has not passed meconium, accompanied by bilious vomiting
and abdominal distention. The nurse should suspect:
A) Normal newborn adaptation
B) Necrotizing enterocolitis
C) Intestinal obstruction
D) Gastroesophageal reflux
Correct Answer: C) Intestinal obstruction
Rationale: Failure to pass meconium within 48 hours, along with bilious emesis and a distended
abdomen, is a classic presentation of an intestinal obstruction such as meconium ileus or
Hirschsprung's disease and requires immediate provider notification .
3. A patient in active labor experiences a prolonged second stage. After the fetal head delivers, it
retracts tightly against the perineum and does not recede. Which action should the nurse take
immediately?
A) Apply gentle suprapubic pressure
,B) Position the client in a hands-and-knees position
C) Call for assistance and prepare for shoulder dystocia maneuvers
D) Apply fundal pressure
Correct Answer: C) Call for assistance and prepare for shoulder dystocia maneuvers
Rationale: The "turtle sign" indicates shoulder dystocia. The nurse should call for assistance and
prepare for maneuvers like McRoberts' positioning and suprapubic pressure. Fundal pressure is
contraindicated as it can worsen impaction .
4. A client with preeclampsia is receiving a magnesium sulfate infusion. Which assessment
finding indicates magnesium toxicity?
A) Respiratory rate of 16 breaths/min
B) Urine output of 40 mL/hr
C) Absent deep tendon reflexes
D) Serum magnesium level of 5 mEq/L
Correct Answer: C) Absent deep tendon reflexes
Rationale: A sign of magnesium toxicity is the loss of deep tendon reflexes (DTRs). Other signs
include a respiratory rate under 12 breaths/min and urine output below 30 mL/hr. The antidote is
calcium gluconate .
5. An infant of a diabetic mother is at risk for which complication due to hyperinsulinism?
A) Hyperglycemia
B) Hypoglycemia
C) Hypercalcemia
D) Hyperbilirubinemia
Correct Answer: B) Hypoglycemia
,Rationale: Infants of diabetic mothers experience fetal hyperglycemia, leading to fetal
hyperinsulinemia. After birth, the continued high insulin production causes rapid glucose
utilization, resulting in neonatal hypoglycemia .
6. A charge nurse is planning the shift assignment and has an RN and a PN on the team. Which
client should the charge nurse assign to the RN?
A) A 75-year old client with renal calculi who requires urine straining
B) A 64-year old client who had a total hip replacement the previous day
C) A 30-year old depressed client who admits to suicide ideation
D) An adolescent with multiple contusions due to a fall that occurred 2 days ago
Correct Answer: C) A 30-year old depressed client who admits to suicide ideation
Rationale: The RN should be assigned to the client with suicide ideation because it requires
complex assessment, crisis intervention, and the creation of a safety plan, which are beyond the
scope of practical nursing .
7. A patient with pancreatitis complains of severe epigastric pain. Ten minutes after receiving a
narcotic analgesic, the client insists on sitting up and leaning forward. Which intervention should
the nurse implement?
A) Raise HOB to 90 degrees
B) Position bedside table so the client can lean across it
C) Place bed in a reverse Trendelenburg position
D) Encourage rest until the analgesic becomes effective
Correct Answer: B) Position bedside table so the client can lean across it
Rationale: Leaning forward often reduces pain for clients with pancreatitis. The nurse should
facilitate this position by providing a stable surface for them to lean on, as it relieves tension on
the pancreas .
8. A male client with a brain tumor has a tonic-clonic seizure lasting 50 seconds. Following the
seizure, he is lethargic and confused, and his wife reports this is his first seizure. Which action
should the nurse take?
, A) Ask the wife to wait outside the room
B) Keep orienting the client to time and place until he is less confused
C) Notify the emergency response team of the client's seizure
D) Explain the postictal state that usually follows seizures
Correct Answer: D) Explain the postictal state that usually follows seizures
Rationale: The postictal phase of a seizure is characterized by confusion and lethargy. The nurse
should provide education to the wife about this expected phase to alleviate anxiety about the
client's new onset of symptoms .
9. A nurse is providing lifestyle change education for a client to slow the progression of coronary
artery disease. Which statement made by the client should the nurse recognize as needing
additional education? (Select all that apply)
A) Keep a food diary.
B) Eat more canned vegetables.
C) Consume foods with saturated fat.
D) Walk 30 minutes per day.
E) Include oatmeal for breakfast.
F) Use a salt substitute
Correct Answer: B) Eat more canned vegetables. C) Consume foods with saturated fats.
Rationale: Canned vegetables are high in sodium, and foods high in saturated fat contribute to
plaque buildup. A heart-healthy diet emphasizes fresh produce, whole grains, and lean proteins.
Clients should also monitor sodium intake and choose unsaturated fats .
10. While caring for a toddler receiving oxygen via facemask, the nurse observes that the child's
lips and nares are dry and cracked. Which intervention should the nurse implement?
A) Use a water-soluble lubricant on affected oral and nasal mucosa.
B) Use a topical lidocaine analgesic for cracked lips.
C) Ask the mother what she usually uses on the child's lips and nose.
QUESTIONS AND ANSWERS + RATIONALES | STUDY GUIDE |
100% CORRECT
1. The turtle sign (retraction of the fetal head against the perineum after delivery) indicates which
obstetric emergency?
A) Nuchal cord
B) Shoulder dystocia
C) Uterine rupture
D) Placental abruption
Correct Answer: B) Shoulder dystocia
Rationale: The "turtle sign" is the hallmark of shoulder dystocia, where the fetal shoulders are
impacted behind the maternal symphysis pubis. The nurse should immediately call for assistance
and prepare for maneuvers such as McRoberts' and suprapubic pressure .
2. A newborn is 12 hours old and has not passed meconium, accompanied by bilious vomiting
and abdominal distention. The nurse should suspect:
A) Normal newborn adaptation
B) Necrotizing enterocolitis
C) Intestinal obstruction
D) Gastroesophageal reflux
Correct Answer: C) Intestinal obstruction
Rationale: Failure to pass meconium within 48 hours, along with bilious emesis and a distended
abdomen, is a classic presentation of an intestinal obstruction such as meconium ileus or
Hirschsprung's disease and requires immediate provider notification .
3. A patient in active labor experiences a prolonged second stage. After the fetal head delivers, it
retracts tightly against the perineum and does not recede. Which action should the nurse take
immediately?
A) Apply gentle suprapubic pressure
,B) Position the client in a hands-and-knees position
C) Call for assistance and prepare for shoulder dystocia maneuvers
D) Apply fundal pressure
Correct Answer: C) Call for assistance and prepare for shoulder dystocia maneuvers
Rationale: The "turtle sign" indicates shoulder dystocia. The nurse should call for assistance and
prepare for maneuvers like McRoberts' positioning and suprapubic pressure. Fundal pressure is
contraindicated as it can worsen impaction .
4. A client with preeclampsia is receiving a magnesium sulfate infusion. Which assessment
finding indicates magnesium toxicity?
A) Respiratory rate of 16 breaths/min
B) Urine output of 40 mL/hr
C) Absent deep tendon reflexes
D) Serum magnesium level of 5 mEq/L
Correct Answer: C) Absent deep tendon reflexes
Rationale: A sign of magnesium toxicity is the loss of deep tendon reflexes (DTRs). Other signs
include a respiratory rate under 12 breaths/min and urine output below 30 mL/hr. The antidote is
calcium gluconate .
5. An infant of a diabetic mother is at risk for which complication due to hyperinsulinism?
A) Hyperglycemia
B) Hypoglycemia
C) Hypercalcemia
D) Hyperbilirubinemia
Correct Answer: B) Hypoglycemia
,Rationale: Infants of diabetic mothers experience fetal hyperglycemia, leading to fetal
hyperinsulinemia. After birth, the continued high insulin production causes rapid glucose
utilization, resulting in neonatal hypoglycemia .
6. A charge nurse is planning the shift assignment and has an RN and a PN on the team. Which
client should the charge nurse assign to the RN?
A) A 75-year old client with renal calculi who requires urine straining
B) A 64-year old client who had a total hip replacement the previous day
C) A 30-year old depressed client who admits to suicide ideation
D) An adolescent with multiple contusions due to a fall that occurred 2 days ago
Correct Answer: C) A 30-year old depressed client who admits to suicide ideation
Rationale: The RN should be assigned to the client with suicide ideation because it requires
complex assessment, crisis intervention, and the creation of a safety plan, which are beyond the
scope of practical nursing .
7. A patient with pancreatitis complains of severe epigastric pain. Ten minutes after receiving a
narcotic analgesic, the client insists on sitting up and leaning forward. Which intervention should
the nurse implement?
A) Raise HOB to 90 degrees
B) Position bedside table so the client can lean across it
C) Place bed in a reverse Trendelenburg position
D) Encourage rest until the analgesic becomes effective
Correct Answer: B) Position bedside table so the client can lean across it
Rationale: Leaning forward often reduces pain for clients with pancreatitis. The nurse should
facilitate this position by providing a stable surface for them to lean on, as it relieves tension on
the pancreas .
8. A male client with a brain tumor has a tonic-clonic seizure lasting 50 seconds. Following the
seizure, he is lethargic and confused, and his wife reports this is his first seizure. Which action
should the nurse take?
, A) Ask the wife to wait outside the room
B) Keep orienting the client to time and place until he is less confused
C) Notify the emergency response team of the client's seizure
D) Explain the postictal state that usually follows seizures
Correct Answer: D) Explain the postictal state that usually follows seizures
Rationale: The postictal phase of a seizure is characterized by confusion and lethargy. The nurse
should provide education to the wife about this expected phase to alleviate anxiety about the
client's new onset of symptoms .
9. A nurse is providing lifestyle change education for a client to slow the progression of coronary
artery disease. Which statement made by the client should the nurse recognize as needing
additional education? (Select all that apply)
A) Keep a food diary.
B) Eat more canned vegetables.
C) Consume foods with saturated fat.
D) Walk 30 minutes per day.
E) Include oatmeal for breakfast.
F) Use a salt substitute
Correct Answer: B) Eat more canned vegetables. C) Consume foods with saturated fats.
Rationale: Canned vegetables are high in sodium, and foods high in saturated fat contribute to
plaque buildup. A heart-healthy diet emphasizes fresh produce, whole grains, and lean proteins.
Clients should also monitor sodium intake and choose unsaturated fats .
10. While caring for a toddler receiving oxygen via facemask, the nurse observes that the child's
lips and nares are dry and cracked. Which intervention should the nurse implement?
A) Use a water-soluble lubricant on affected oral and nasal mucosa.
B) Use a topical lidocaine analgesic for cracked lips.
C) Ask the mother what she usually uses on the child's lips and nose.
