NUR166/NUR 166 Final Exam V2 |
Concepts of Family Centered Nursing for
the Practical Nurse Q&A with Rationale |
Hondros College of Nursing
1. A nurse is calculating the estimated date of delivery using Naegele’s rule for a client whose
last menstrual period began on May 4th. Which of the following is the correct due date?
A. January 28th
B. February 4th
C. February 11th
D. March 11th
Correct Answer: C
Rationale: To calculate the estimated date of delivery using Naegele’s rule, the nurse
subtracts 3 months and adds 7 days to the first day of the last menstrual period. For a
period starting May 4th, subtracting 3 months brings the date back to February, and adding
7 days results in February 11th. This formula is a standard method used in prenatal care to
provide an estimated timeframe for birth.
2. A nurse is assessing a client who is at 32 weeks of gestation and reports a sudden gush of
clear fluid from the vagina. Which of the following is the priority nursing action?
A. Perform a nitrazine test on the fluid.
,B. Assess the fetal heart rate.
C. Check the client’s temperature.
D. Determine the time of the fluid gush.
Correct Answer: B
Rationale: The priority action when a rupture of membranes is suspected is to assess the
fetal heart rate to ensure fetal well-being. A sudden loss of fluid can lead to umbilical cord
prolapse, which is a medical emergency that compromises fetal oxygenation. While
nitrazine testing and temperature checks are important, the immediate safety of the fetus
takes precedence in this scenario.
3. A nurse is providing teaching to a client who is in the first trimester of pregnancy about
common discomforts. Which of the following instructions should the nurse include?
A. Increase fluid intake just before bedtime.
B. Eat dry crackers before arising in the morning.
C. Avoid wearing a supportive bra during the day.
D. Perform vigorous exercise to reduce fatigue.
Correct Answer: B
Rationale: Eating dry crackers or toast before getting out of bed helps settle the stomach
and manage morning sickness during the first trimester. This intervention addresses the
, hormonal changes that slow digestion and cause nausea. The nurse should also advise the
client to eat small, frequent meals throughout the day to prevent an empty stomach.
4. A nurse is caring for a client who is in the second stage of labor. The nurse notes the fetal
head is crowning. Which of the following actions should the nurse take?
A. Instruct the client to push as hard as possible.
B. Prepare for an immediate cesarean birth.
C. Encourage the client to pant or blow.
D. Apply fundal pressure to assist the birth.
Correct Answer: C
Rationale: When the fetal head is crowning, the nurse should encourage the client to pant
or blow to avoid rapid expulsion of the head. This technique helps minimize the risk of
perineal lacerations and allows for a more controlled delivery. The nurse should never
apply fundal pressure as it can cause uterine rupture or fetal injury.
5. A nurse is assessing a newborn 1 minute after birth and observes the following: heart rate
110/min, slow/irregular respirations, some flexion of extremities, grimace in response to
suctioning, and a pink body with blue extremities. What is the Apgar score?
A. 5
B. 7
C. 6
Concepts of Family Centered Nursing for
the Practical Nurse Q&A with Rationale |
Hondros College of Nursing
1. A nurse is calculating the estimated date of delivery using Naegele’s rule for a client whose
last menstrual period began on May 4th. Which of the following is the correct due date?
A. January 28th
B. February 4th
C. February 11th
D. March 11th
Correct Answer: C
Rationale: To calculate the estimated date of delivery using Naegele’s rule, the nurse
subtracts 3 months and adds 7 days to the first day of the last menstrual period. For a
period starting May 4th, subtracting 3 months brings the date back to February, and adding
7 days results in February 11th. This formula is a standard method used in prenatal care to
provide an estimated timeframe for birth.
2. A nurse is assessing a client who is at 32 weeks of gestation and reports a sudden gush of
clear fluid from the vagina. Which of the following is the priority nursing action?
A. Perform a nitrazine test on the fluid.
,B. Assess the fetal heart rate.
C. Check the client’s temperature.
D. Determine the time of the fluid gush.
Correct Answer: B
Rationale: The priority action when a rupture of membranes is suspected is to assess the
fetal heart rate to ensure fetal well-being. A sudden loss of fluid can lead to umbilical cord
prolapse, which is a medical emergency that compromises fetal oxygenation. While
nitrazine testing and temperature checks are important, the immediate safety of the fetus
takes precedence in this scenario.
3. A nurse is providing teaching to a client who is in the first trimester of pregnancy about
common discomforts. Which of the following instructions should the nurse include?
A. Increase fluid intake just before bedtime.
B. Eat dry crackers before arising in the morning.
C. Avoid wearing a supportive bra during the day.
D. Perform vigorous exercise to reduce fatigue.
Correct Answer: B
Rationale: Eating dry crackers or toast before getting out of bed helps settle the stomach
and manage morning sickness during the first trimester. This intervention addresses the
, hormonal changes that slow digestion and cause nausea. The nurse should also advise the
client to eat small, frequent meals throughout the day to prevent an empty stomach.
4. A nurse is caring for a client who is in the second stage of labor. The nurse notes the fetal
head is crowning. Which of the following actions should the nurse take?
A. Instruct the client to push as hard as possible.
B. Prepare for an immediate cesarean birth.
C. Encourage the client to pant or blow.
D. Apply fundal pressure to assist the birth.
Correct Answer: C
Rationale: When the fetal head is crowning, the nurse should encourage the client to pant
or blow to avoid rapid expulsion of the head. This technique helps minimize the risk of
perineal lacerations and allows for a more controlled delivery. The nurse should never
apply fundal pressure as it can cause uterine rupture or fetal injury.
5. A nurse is assessing a newborn 1 minute after birth and observes the following: heart rate
110/min, slow/irregular respirations, some flexion of extremities, grimace in response to
suctioning, and a pink body with blue extremities. What is the Apgar score?
A. 5
B. 7
C. 6
