NUR166/NUR 166 Exam 3 V2 | Concepts of
Family Centered Nursing for the Practical
Nurse Q&A with Rationale | Hondros
College of Nursing
1. A nurse is assessing a client who is at 34 weeks of gestation and has a prescription for a
nonstress test (NST). Which of the following findings indicates a reactive NST?
A. Presence of at least two fetal heart rate accelerations in a 20-minute period.
B. Absence of fetal heart rate accelerations during the testing period.
C. Presence of variable decelerations with fetal movement.
D. Fetal heart rate baseline of 110 beats per minute with no variability.
Correct Answer: A
Rationale: A reactive nonstress test is defined by the presence of at least two fetal heart
rate accelerations of at least 15 bpm above baseline lasting for 15 seconds within a 20-
minute window. This indicates fetal well-being and adequate oxygenation of the fetus. If
these criteria are not met within 40 minutes, the test is considered nonreactive and
requires further evaluation.
2. A practical nurse is providing discharge teaching to the parents of a newborn regarding
umbilical cord care. Which of the following instructions should the nurse include?
A. Keep the diaper folded down below the umbilical cord stump.
,B. Clean the cord with hydrogen peroxide at every diaper change.
C. Bathe the infant in a tub of warm water daily until the cord falls off.
D. Apply a petroleum jelly dressing to the cord stump twice daily.
Correct Answer: A
Rationale: Keeping the diaper folded below the umbilical cord stump prevents irritation
and allows the area to stay dry, which facilitates the healing process. Parents should be
taught to clean the area with plain water if it becomes soiled and to avoid submerging the
cord in water until it has fallen off. The cord typically falls off within 10 to 14 days, and
signs of infection like redness or foul odor should be reported immediately.
3. A nurse is caring for a client who is in the first stage of labor and has an umbilical cord
prolapse. Which of the following actions should the nurse take first?
A. Apply upward pressure against the presenting part with a gloved hand.
B. Administer oxygen via a nonrebreather mask at 10 L/min.
C. Increase the rate of the intravenous infusion.
D. Prepare the client for an emergency cesarean section.
Correct Answer: A
Rationale: Umbilical cord prolapse is a medical emergency because the presenting part of
the fetus can compress the cord, compromising blood flow and oxygen to the fetus. The
priority action is to use a sterile gloved hand to apply upward pressure on the fetal
,presenting part to relieve cord compression. This action must be maintained until the
delivery of the infant, usually via emergency cesarean section, is completed.
4. A nurse is assessing a child who has acute glomerulonephritis. Which of the following
findings should the nurse expect?
A. Hypotension and polyuria.
B. Periorbital edema and smoky-colored urine.
C. Increased appetite and weight loss.
D. Low blood urea nitrogen (BUN) levels.
Correct Answer: B
Rationale: Acute glomerulonephritis is often characterized by the sudden onset of
periorbital edema, hypertension, and hematuria, which gives the urine a smoky or tea-
colored appearance. This condition frequently follows a streptococcal infection of the
throat or skin. Management includes monitoring blood pressure, managing fluid balance,
and assessing renal function through BUN and creatinine levels.
5. A postpartum nurse is assessing a client 4 hours after a vaginal delivery. The nurse notes
the fundus is firm, shifted to the right, and two fingerbreadths above the umbilicus. Which of
the following actions should the nurse take?
A. Assist the client to the bathroom to void.
B. Massage the fundus vigorously.
C. Notify the provider of a suspected hemorrhage.
, D. Administer an oxytocic medication as ordered.
Correct Answer: A
Rationale: A fundus that is displaced to the right and elevated above the umbilicus is a
classic sign of bladder distention. A full bladder prevents the uterus from contracting
effectively, which increases the risk of postpartum hemorrhage. Assisting the client to
empty her bladder should allow the uterus to return to the midline and descend to the
appropriate level.
6. A nurse is reinforcing teaching with the mother of a 4-year-old child who has a new
diagnosis of pinworms. Which of the following instructions should the nurse include?
A. The child should take a tub bath every morning for 2 weeks.
B. Linens should be washed in cold water to prevent egg dispersal.
C. All family members should be treated with medication.
D. Give the child a high-fiber diet to help expel the worms.
Correct Answer: C
Rationale: Pinworms (Enterobius vermicularis) are highly contagious, and it is common
for the entire household to be infected. Therefore, medical treatment for all family
members is recommended to prevent reinfection. Parents should also be taught to wash all
bedding and clothing in hot water and ensure children keep their fingernails short to
prevent the spread of eggs.
Family Centered Nursing for the Practical
Nurse Q&A with Rationale | Hondros
College of Nursing
1. A nurse is assessing a client who is at 34 weeks of gestation and has a prescription for a
nonstress test (NST). Which of the following findings indicates a reactive NST?
A. Presence of at least two fetal heart rate accelerations in a 20-minute period.
B. Absence of fetal heart rate accelerations during the testing period.
C. Presence of variable decelerations with fetal movement.
D. Fetal heart rate baseline of 110 beats per minute with no variability.
Correct Answer: A
Rationale: A reactive nonstress test is defined by the presence of at least two fetal heart
rate accelerations of at least 15 bpm above baseline lasting for 15 seconds within a 20-
minute window. This indicates fetal well-being and adequate oxygenation of the fetus. If
these criteria are not met within 40 minutes, the test is considered nonreactive and
requires further evaluation.
2. A practical nurse is providing discharge teaching to the parents of a newborn regarding
umbilical cord care. Which of the following instructions should the nurse include?
A. Keep the diaper folded down below the umbilical cord stump.
,B. Clean the cord with hydrogen peroxide at every diaper change.
C. Bathe the infant in a tub of warm water daily until the cord falls off.
D. Apply a petroleum jelly dressing to the cord stump twice daily.
Correct Answer: A
Rationale: Keeping the diaper folded below the umbilical cord stump prevents irritation
and allows the area to stay dry, which facilitates the healing process. Parents should be
taught to clean the area with plain water if it becomes soiled and to avoid submerging the
cord in water until it has fallen off. The cord typically falls off within 10 to 14 days, and
signs of infection like redness or foul odor should be reported immediately.
3. A nurse is caring for a client who is in the first stage of labor and has an umbilical cord
prolapse. Which of the following actions should the nurse take first?
A. Apply upward pressure against the presenting part with a gloved hand.
B. Administer oxygen via a nonrebreather mask at 10 L/min.
C. Increase the rate of the intravenous infusion.
D. Prepare the client for an emergency cesarean section.
Correct Answer: A
Rationale: Umbilical cord prolapse is a medical emergency because the presenting part of
the fetus can compress the cord, compromising blood flow and oxygen to the fetus. The
priority action is to use a sterile gloved hand to apply upward pressure on the fetal
,presenting part to relieve cord compression. This action must be maintained until the
delivery of the infant, usually via emergency cesarean section, is completed.
4. A nurse is assessing a child who has acute glomerulonephritis. Which of the following
findings should the nurse expect?
A. Hypotension and polyuria.
B. Periorbital edema and smoky-colored urine.
C. Increased appetite and weight loss.
D. Low blood urea nitrogen (BUN) levels.
Correct Answer: B
Rationale: Acute glomerulonephritis is often characterized by the sudden onset of
periorbital edema, hypertension, and hematuria, which gives the urine a smoky or tea-
colored appearance. This condition frequently follows a streptococcal infection of the
throat or skin. Management includes monitoring blood pressure, managing fluid balance,
and assessing renal function through BUN and creatinine levels.
5. A postpartum nurse is assessing a client 4 hours after a vaginal delivery. The nurse notes
the fundus is firm, shifted to the right, and two fingerbreadths above the umbilicus. Which of
the following actions should the nurse take?
A. Assist the client to the bathroom to void.
B. Massage the fundus vigorously.
C. Notify the provider of a suspected hemorrhage.
, D. Administer an oxytocic medication as ordered.
Correct Answer: A
Rationale: A fundus that is displaced to the right and elevated above the umbilicus is a
classic sign of bladder distention. A full bladder prevents the uterus from contracting
effectively, which increases the risk of postpartum hemorrhage. Assisting the client to
empty her bladder should allow the uterus to return to the midline and descend to the
appropriate level.
6. A nurse is reinforcing teaching with the mother of a 4-year-old child who has a new
diagnosis of pinworms. Which of the following instructions should the nurse include?
A. The child should take a tub bath every morning for 2 weeks.
B. Linens should be washed in cold water to prevent egg dispersal.
C. All family members should be treated with medication.
D. Give the child a high-fiber diet to help expel the worms.
Correct Answer: C
Rationale: Pinworms (Enterobius vermicularis) are highly contagious, and it is common
for the entire household to be infected. Therefore, medical treatment for all family
members is recommended to prevent reinfection. Parents should also be taught to wash all
bedding and clothing in hot water and ensure children keep their fingernails short to
prevent the spread of eggs.
