NUR 231 Final Exam Actual Exam V2 | NUR 231 Childbearing & Child
Caring Family (NUR231 Final Exam) | Galen College of Nursing
1. A 32-year-old primigravida at 38 weeks gestation presents with a blood pressure of 152/96
mmHg and 2+ proteinuria. Which assessment finding should the nurse prioritize as an
indicator of worsening preeclampsia?
A. Increased fetal movement
B. Report of a mild tension headache
C. Trace edema in the lower extremities
D. Epigastric pain or RUQ tenderness
Answer: D
Rationale: Epigastric pain or right upper quadrant (RUQ) tenderness often signifies liver
involvement and edema, indicating a progression toward HELLP syndrome or eclampsia.
While a headache is concerning, epigastric pain is a critical warning sign of hepatic
ischemia. This finding requires immediate notification of the provider to prevent seizures
or hepatic rupture.
2. During a routine prenatal visit, a client at 24 weeks gestation asks about the purpose of the
1-hour Glucose Tolerance Test (GTT). How should the nurse explain the rationale for this
screening?
A. To diagnose type 2 diabetes mellitus
B. To assess for fetal macrosomia
C. To identify placental hormones that antagonize insulin
D. To determine the need for immediate insulin therapy
Answer: C
Rationale: Gestational diabetes typically occurs in the second trimester when placental
hormones, such as human placental lactogen, increase insulin resistance in the mother. The
1-hour GTT screens for the body’s ability to handle this increased insulin demand. This test
is a screening tool, not a definitive diagnosis, and is standard for all pregnant women
between 24 and 28 weeks.
3. The nurse is monitoring a fetal heart rate (FHR) tracing and observes late decelerations.
What is the priority nursing intervention in this clinical scenario?
A. Increase the rate of the oxytocin infusion
B. Place the client in a supine position
,C. Administer oxygen via non-rebreather mask at 10 L/min
D. Encourage the client to use patterned breathing
Answer: C
Rationale: Late decelerations are indicative of uteroplacental insufficiency, which reduces
oxygen delivery to the fetus. The nurse must implement intrauterine resuscitation, which
includes administering oxygen, repositioning the mother to her side, and stopping oxytocin.
These actions are designed to maximize maternal-fetal oxygen exchange and improve
placental perfusion.
4. A postpartum nurse is assessing a client two hours after a vaginal delivery. The fundus is
boggy and displaced to the right of the midline. What is the nurse’s first action?
A. Perform vigorous fundal massage
B. Notify the healthcare provider immediately
C. Increase the IV pitocin flow rate
D. Assist the client to empty her bladder
Answer: D
Rationale: A fundus that is displaced to the right of the midline is a classic sign of a
distended bladder. A full bladder prevents the uterus from contracting effectively, which
significantly increases the risk of postpartum hemorrhage. Assisting the patient to void will
allow the uterus to return to the midline and firm up naturally or with minimal massage.
5. A newborn is born via C-section at 39 weeks. At one minute of life, the heart rate is 110,
respiratory effort is slow and irregular, there is some flexion of extremities, the infant
grimaces when suctioned, and the body is pink with blue extremities. What is the Apgar
score?
A. 6
B. 5
C. 7
D. 8
Answer: A
Rationale: The score is calculated as follows: Heart rate >100 (2 points), Respiratory effort
slow/irregular (1 point), Muscle tone some flexion (1 point), Reflex irritability grimace (1
point), and Color acrocyanosis (1 point). This totals 6. This score indicates that the infant
may need some stimulation or intervention to stabilize after birth.
, 6. Which developmental stage, according to Erikson, should the nurse focus on when
providing care for a 4-year-old child hospitalized for a tonsillectomy?
A. Trust vs. Mistrust
B. Initiative vs. Guilt
C. Autonomy vs. Shame and Doubt
D. Industry vs. Inferiority
Answer: B
Rationale: Preschoolers (ages 3 to 6) are in the stage of Initiative vs. Guilt, where they
begin to assert power and control over the world through directing play and other social
interactions. Hospitalization can make them feel a loss of control, leading to feelings of guilt
if they perceive their illness as a punishment. The nurse should encourage the child to
participate in care choices to foster a sense of initiative.
7. An 8-month-old infant is admitted with severe dehydration due to gastroenteritis. Which
assessment finding should the nurse report to the provider as a sign of late-stage
dehydration?
A. Moist mucous membranes
B. Blood pressure of 60/40 mmHg
C. Sunken fontanels and tachycardia
D. Capillary refill of 2 seconds
Answer: B
Rationale: In infants, blood pressure is maintained until late in the process of dehydration;
therefore, hypotension is an ominous sign of impending circulatory collapse. Sunken
fontanels and tachycardia are signs of moderate dehydration but are seen earlier than a
drop in blood pressure. Immediate fluid resuscitation is required when an infant becomes
hypotensive due to fluid loss.
8. A nurse is teaching the parents of a toddler about home safety. Which statement by the
parents indicates the need for further education?
A. We keep all cleaning supplies in a locked cabinet under the sink.
B. We placed the car seat in the front passenger seat so we can see the baby.
C. We have turned the water heater down to 120 degrees Fahrenheit.
D. We use safety gates at both the top and bottom of the stairs.
Answer: B
Caring Family (NUR231 Final Exam) | Galen College of Nursing
1. A 32-year-old primigravida at 38 weeks gestation presents with a blood pressure of 152/96
mmHg and 2+ proteinuria. Which assessment finding should the nurse prioritize as an
indicator of worsening preeclampsia?
A. Increased fetal movement
B. Report of a mild tension headache
C. Trace edema in the lower extremities
D. Epigastric pain or RUQ tenderness
Answer: D
Rationale: Epigastric pain or right upper quadrant (RUQ) tenderness often signifies liver
involvement and edema, indicating a progression toward HELLP syndrome or eclampsia.
While a headache is concerning, epigastric pain is a critical warning sign of hepatic
ischemia. This finding requires immediate notification of the provider to prevent seizures
or hepatic rupture.
2. During a routine prenatal visit, a client at 24 weeks gestation asks about the purpose of the
1-hour Glucose Tolerance Test (GTT). How should the nurse explain the rationale for this
screening?
A. To diagnose type 2 diabetes mellitus
B. To assess for fetal macrosomia
C. To identify placental hormones that antagonize insulin
D. To determine the need for immediate insulin therapy
Answer: C
Rationale: Gestational diabetes typically occurs in the second trimester when placental
hormones, such as human placental lactogen, increase insulin resistance in the mother. The
1-hour GTT screens for the body’s ability to handle this increased insulin demand. This test
is a screening tool, not a definitive diagnosis, and is standard for all pregnant women
between 24 and 28 weeks.
3. The nurse is monitoring a fetal heart rate (FHR) tracing and observes late decelerations.
What is the priority nursing intervention in this clinical scenario?
A. Increase the rate of the oxytocin infusion
B. Place the client in a supine position
,C. Administer oxygen via non-rebreather mask at 10 L/min
D. Encourage the client to use patterned breathing
Answer: C
Rationale: Late decelerations are indicative of uteroplacental insufficiency, which reduces
oxygen delivery to the fetus. The nurse must implement intrauterine resuscitation, which
includes administering oxygen, repositioning the mother to her side, and stopping oxytocin.
These actions are designed to maximize maternal-fetal oxygen exchange and improve
placental perfusion.
4. A postpartum nurse is assessing a client two hours after a vaginal delivery. The fundus is
boggy and displaced to the right of the midline. What is the nurse’s first action?
A. Perform vigorous fundal massage
B. Notify the healthcare provider immediately
C. Increase the IV pitocin flow rate
D. Assist the client to empty her bladder
Answer: D
Rationale: A fundus that is displaced to the right of the midline is a classic sign of a
distended bladder. A full bladder prevents the uterus from contracting effectively, which
significantly increases the risk of postpartum hemorrhage. Assisting the patient to void will
allow the uterus to return to the midline and firm up naturally or with minimal massage.
5. A newborn is born via C-section at 39 weeks. At one minute of life, the heart rate is 110,
respiratory effort is slow and irregular, there is some flexion of extremities, the infant
grimaces when suctioned, and the body is pink with blue extremities. What is the Apgar
score?
A. 6
B. 5
C. 7
D. 8
Answer: A
Rationale: The score is calculated as follows: Heart rate >100 (2 points), Respiratory effort
slow/irregular (1 point), Muscle tone some flexion (1 point), Reflex irritability grimace (1
point), and Color acrocyanosis (1 point). This totals 6. This score indicates that the infant
may need some stimulation or intervention to stabilize after birth.
, 6. Which developmental stage, according to Erikson, should the nurse focus on when
providing care for a 4-year-old child hospitalized for a tonsillectomy?
A. Trust vs. Mistrust
B. Initiative vs. Guilt
C. Autonomy vs. Shame and Doubt
D. Industry vs. Inferiority
Answer: B
Rationale: Preschoolers (ages 3 to 6) are in the stage of Initiative vs. Guilt, where they
begin to assert power and control over the world through directing play and other social
interactions. Hospitalization can make them feel a loss of control, leading to feelings of guilt
if they perceive their illness as a punishment. The nurse should encourage the child to
participate in care choices to foster a sense of initiative.
7. An 8-month-old infant is admitted with severe dehydration due to gastroenteritis. Which
assessment finding should the nurse report to the provider as a sign of late-stage
dehydration?
A. Moist mucous membranes
B. Blood pressure of 60/40 mmHg
C. Sunken fontanels and tachycardia
D. Capillary refill of 2 seconds
Answer: B
Rationale: In infants, blood pressure is maintained until late in the process of dehydration;
therefore, hypotension is an ominous sign of impending circulatory collapse. Sunken
fontanels and tachycardia are signs of moderate dehydration but are seen earlier than a
drop in blood pressure. Immediate fluid resuscitation is required when an infant becomes
hypotensive due to fluid loss.
8. A nurse is teaching the parents of a toddler about home safety. Which statement by the
parents indicates the need for further education?
A. We keep all cleaning supplies in a locked cabinet under the sink.
B. We placed the car seat in the front passenger seat so we can see the baby.
C. We have turned the water heater down to 120 degrees Fahrenheit.
D. We use safety gates at both the top and bottom of the stairs.
Answer: B
