NUR 230 Final Exam V3 | NUR 230 The Childbearing / Child Caring
Family | Q&A with Rationale (NUR230 Final Exam) | Galen College of
Nursing
1. A nurse is assessing a client who is at 32 weeks of gestation and has a history of
preeclampsia. Which of the following findings should the nurse report to the provider
immediately?
A. 1+ pitting edema in the lower extremities
B. A blood pressure reading of 138/88 mmHg
C. Weight gain of 0.5 kg (1.1 lb) in one week
D. Epigastric pain or right upper quadrant tenderness
Answer: D
Explanation: Epigastric pain or right upper quadrant tenderness is a classic sign of liver
involvement and impending eclampsia or HELLP syndrome. This finding suggests hepatic
ischemia or subcapsular hematoma, which are medical emergencies. The nurse must act
quickly to prevent seizure activity or organ rupture in the pregnant client.
2. A nurse is caring for a client in the second stage of labor. The fetal heart rate monitor
shows late decelerations. Which action should the nurse take first?
A. Assist the client into a side-lying position
B. Increase the rate of the oxytocin infusion
C. Perform a vaginal examination to check for cord prolapse
D. Prepare for an immediate forceps delivery
Answer: A
Explanation: Late decelerations indicate uteroplacental insufficiency, and the first nursing
action is to optimize oxygen delivery to the fetus. Repositioning the mother to a side-lying
(lateral) position relieves pressure on the vena cava and improves placental perfusion.
Additional interventions include stopping oxytocin, increasing IV fluids, and applying
oxygen via non-rebreather mask.
3. Which of the following medications should the nurse prepare to administer to a newborn
within 1 to 2 hours of birth to prevent ophthalmia neonatorum?
A. Vitamin K (Phytonadione)
B. Erythromycin ophthalmic ointment
C. Hepatitis B vaccine
,D. Nystatin oral suspension
Answer: B
Explanation: Erythromycin ophthalmic ointment is legally mandated in many regions to
prevent neonatal blindness caused by Neisseria gonorrhoeae or Chlamydia trachomatis.
The medication is applied to the conjunctival sac of each eye shortly after birth. Failure to
provide this prophylaxis can lead to severe infections acquired during the passage through
the birth canal.
4. A nurse is evaluating a client’s understanding of the GTPAL system. The client reports she is
currently pregnant, has a 3-year-old born at 39 weeks, and had a miscarriage at 10 weeks.
How should the nurse document this?
A. G3, T1, P0, A1, L1
B. G2, T1, P1, A0, L1
C. G3, T2, P0, A1, L2
D. G2, T1, P0, A1, L1
Answer: A
Explanation: The client is currently pregnant (Gravida 3), has one full-term child (Term 1),
zero preterm births (Preterm 0), one miscarriage (Abortion 1), and one living child (Living
1). The current pregnancy counts toward Gravida but not Term or Preterm until delivery.
Accurately recording obstetric history is vital for identifying potential risks in the current
pregnancy.
5. A nurse is teaching a parent about the care of a child with a diagnosis of Tetralogy of Fallot.
Which of the following instructions should be included regarding ‘Tet spells’?
A. Place the child in a knee-chest position during an episode
B. Administer high-flow oxygen via a simple face mask immediately
C. Encourage the child to run and play to increase circulation
D. Keep the child in a supine position with legs straight
Answer: A
Explanation: The knee-chest position increases systemic vascular resistance, which helps
reduce the right-to-left shunt and improves oxygenation during a hypercyanotic spell. This
maneuver is the priority intervention to increase blood flow to the lungs. Parents must be
educated to recognize cyanosis and irritability as precursors to these dangerous episodes.
6. A 10-month-old infant is brought to the clinic for a well-child visit. Which developmental
milestone should the nurse expect the infant to have achieved?
A. Walking without assistance
, B. Building a tower of six blocks
C. Sitting steadily without support
D. Speaking in three-word sentences
Answer: C
Explanation: By 8 to 10 months, infants should be able to sit steadily without support and
may begin to pull themselves to a standing position. Walking independently typically
occurs between 12 and 15 months, while complex sentences occur much later.
Understanding these milestones allows the nurse to identify developmental delays early in
childhood.
7. A nurse is caring for a client receiving Magnesium Sulfate for preeclampsia. The nurse
notes the client’s respiratory rate is 10/min and deep tendon reflexes are absent. What is the
priority action?
A. Stop the Magnesium Sulfate infusion
B. Continue to monitor the client closely
C. Increase the IV fluid maintenance rate
D. Administer Terbutaline subcutaneously
Answer: A
Explanation: Respiratory depression (less than 12/min) and loss of deep tendon reflexes
are classic signs of magnesium toxicity. The nurse must immediately stop the infusion to
prevent cardiac arrest and respiratory failure. Calcium gluconate should be kept at the
bedside as the specific antidote for magnesium toxicity.
8. A nurse is providing discharge instructions to a postpartum client who is breastfeeding.
Which statement by the client indicates a need for further teaching?
A. I should drink plenty of fluids to stay hydrated
B. I will continue to take my prenatal vitamins while nursing
C. I will feed my baby on a strict schedule every 4 hours
D. I will check for my baby’s hunger cues like rooting and sucking
Answer: C
Explanation: Breastfeeding should be done on demand rather than on a strict schedule,
typically 8 to 12 times in a 24-hour period. Feeding on demand ensures the infant receives
adequate nutrition and helps establish the mother’s milk supply. A strict 4-hour schedule
may lead to dehydration in the newborn and mastitis in the mother.
Family | Q&A with Rationale (NUR230 Final Exam) | Galen College of
Nursing
1. A nurse is assessing a client who is at 32 weeks of gestation and has a history of
preeclampsia. Which of the following findings should the nurse report to the provider
immediately?
A. 1+ pitting edema in the lower extremities
B. A blood pressure reading of 138/88 mmHg
C. Weight gain of 0.5 kg (1.1 lb) in one week
D. Epigastric pain or right upper quadrant tenderness
Answer: D
Explanation: Epigastric pain or right upper quadrant tenderness is a classic sign of liver
involvement and impending eclampsia or HELLP syndrome. This finding suggests hepatic
ischemia or subcapsular hematoma, which are medical emergencies. The nurse must act
quickly to prevent seizure activity or organ rupture in the pregnant client.
2. A nurse is caring for a client in the second stage of labor. The fetal heart rate monitor
shows late decelerations. Which action should the nurse take first?
A. Assist the client into a side-lying position
B. Increase the rate of the oxytocin infusion
C. Perform a vaginal examination to check for cord prolapse
D. Prepare for an immediate forceps delivery
Answer: A
Explanation: Late decelerations indicate uteroplacental insufficiency, and the first nursing
action is to optimize oxygen delivery to the fetus. Repositioning the mother to a side-lying
(lateral) position relieves pressure on the vena cava and improves placental perfusion.
Additional interventions include stopping oxytocin, increasing IV fluids, and applying
oxygen via non-rebreather mask.
3. Which of the following medications should the nurse prepare to administer to a newborn
within 1 to 2 hours of birth to prevent ophthalmia neonatorum?
A. Vitamin K (Phytonadione)
B. Erythromycin ophthalmic ointment
C. Hepatitis B vaccine
,D. Nystatin oral suspension
Answer: B
Explanation: Erythromycin ophthalmic ointment is legally mandated in many regions to
prevent neonatal blindness caused by Neisseria gonorrhoeae or Chlamydia trachomatis.
The medication is applied to the conjunctival sac of each eye shortly after birth. Failure to
provide this prophylaxis can lead to severe infections acquired during the passage through
the birth canal.
4. A nurse is evaluating a client’s understanding of the GTPAL system. The client reports she is
currently pregnant, has a 3-year-old born at 39 weeks, and had a miscarriage at 10 weeks.
How should the nurse document this?
A. G3, T1, P0, A1, L1
B. G2, T1, P1, A0, L1
C. G3, T2, P0, A1, L2
D. G2, T1, P0, A1, L1
Answer: A
Explanation: The client is currently pregnant (Gravida 3), has one full-term child (Term 1),
zero preterm births (Preterm 0), one miscarriage (Abortion 1), and one living child (Living
1). The current pregnancy counts toward Gravida but not Term or Preterm until delivery.
Accurately recording obstetric history is vital for identifying potential risks in the current
pregnancy.
5. A nurse is teaching a parent about the care of a child with a diagnosis of Tetralogy of Fallot.
Which of the following instructions should be included regarding ‘Tet spells’?
A. Place the child in a knee-chest position during an episode
B. Administer high-flow oxygen via a simple face mask immediately
C. Encourage the child to run and play to increase circulation
D. Keep the child in a supine position with legs straight
Answer: A
Explanation: The knee-chest position increases systemic vascular resistance, which helps
reduce the right-to-left shunt and improves oxygenation during a hypercyanotic spell. This
maneuver is the priority intervention to increase blood flow to the lungs. Parents must be
educated to recognize cyanosis and irritability as precursors to these dangerous episodes.
6. A 10-month-old infant is brought to the clinic for a well-child visit. Which developmental
milestone should the nurse expect the infant to have achieved?
A. Walking without assistance
, B. Building a tower of six blocks
C. Sitting steadily without support
D. Speaking in three-word sentences
Answer: C
Explanation: By 8 to 10 months, infants should be able to sit steadily without support and
may begin to pull themselves to a standing position. Walking independently typically
occurs between 12 and 15 months, while complex sentences occur much later.
Understanding these milestones allows the nurse to identify developmental delays early in
childhood.
7. A nurse is caring for a client receiving Magnesium Sulfate for preeclampsia. The nurse
notes the client’s respiratory rate is 10/min and deep tendon reflexes are absent. What is the
priority action?
A. Stop the Magnesium Sulfate infusion
B. Continue to monitor the client closely
C. Increase the IV fluid maintenance rate
D. Administer Terbutaline subcutaneously
Answer: A
Explanation: Respiratory depression (less than 12/min) and loss of deep tendon reflexes
are classic signs of magnesium toxicity. The nurse must immediately stop the infusion to
prevent cardiac arrest and respiratory failure. Calcium gluconate should be kept at the
bedside as the specific antidote for magnesium toxicity.
8. A nurse is providing discharge instructions to a postpartum client who is breastfeeding.
Which statement by the client indicates a need for further teaching?
A. I should drink plenty of fluids to stay hydrated
B. I will continue to take my prenatal vitamins while nursing
C. I will feed my baby on a strict schedule every 4 hours
D. I will check for my baby’s hunger cues like rooting and sucking
Answer: C
Explanation: Breastfeeding should be done on demand rather than on a strict schedule,
typically 8 to 12 times in a 24-hour period. Feeding on demand ensures the infant receives
adequate nutrition and helps establish the mother’s milk supply. A strict 4-hour schedule
may lead to dehydration in the newborn and mastitis in the mother.
