NUR166/NUR 166 Exam 4 V1 | Concepts of
Family Centered Nursing for the Practical
Nurse Q&A with Rationale | Hondros
College of Nursing
1. A nurse is providing postpartum teaching to a client about fundal massage. What is the
primary purpose of this intervention?
A. To promote the production of breast milk
B. To decrease the risk of postpartum infection
C. To encourage the return of the menstrual cycle
D. To stimulate uterine contractions and prevent hemorrhage
Correct Answer: D
Rationale: Fundal massage is performed to ensure the uterus remains firm and contracted.
A boggy uterus indicates uterine atony, which is the leading cause of postpartum
hemorrhage. By massaging the fundus, the nurse helps expel clots and maintains muscle
tone to compress bleeding vessels.
2. An infant with hyperbilirubinemia is placed under phototherapy lights. Which nursing
action is a priority for this infant?
A. Apply lotion to the skin to prevent drying
B. Dress the infant in a t-shirt and diaper
,C. Limit fluid intake to prevent overhydration
D. Keep the infant’s eyes covered with opaque shields
Correct Answer: D
Rationale: Protecting the infant’s eyes is a critical safety measure during phototherapy to
prevent retinal damage. The infant should be unclothed, except for a diaper, to maximize
skin exposure to the light. The nurse must also monitor for dehydration and ensure the
infant receives adequate feedings to facilitate bilirubin excretion.
3. A nurse is assessing a 4-year-old child’s growth and development. According to Erikson,
which developmental stage is this child in?
A. Trust vs. Mistrust
B. Initiative vs. Guilt
C. Autonomy vs. Shame and Doubt
D. Industry vs. Inferiority
Correct Answer: B
Rationale: Preschoolers, aged 3 to 6 years, are in the stage of Initiative vs. Guilt. During
this time, they begin to assert power and control over the world through directing play and
other social interaction. If they are discouraged from doing so, they may develop a sense of
guilt regarding their desires.
, 4. Which clinical finding is most characteristic of a child diagnosed with pyloric stenosis?
A. Currant jelly-like stools
B. Bile-stained vomitus
C. Ribbon-like stools
D. Projectile vomiting after feedings
Correct Answer: D
Rationale: Pyloric stenosis involves a thickening of the pyloric sphincter, which creates an
obstruction. This leads to forceful, non-bile-stained projectile vomiting shortly after eating.
The nurse may also palpate an olive-shaped mass in the right upper quadrant of the
abdomen.
5. A nurse is caring for a child with epiglottitis. Which action should the nurse avoid?
A. Using a tongue blade to examine the throat
B. Administering humidified oxygen
C. Monitoring oxygen saturation
D. Keeping the child in an upright position
Correct Answer: A
Rationale: Visualizing the throat with a tongue blade or swab can trigger a laryngospasm
and cause complete airway obstruction in a child with epiglottitis. This condition is a
medical emergency characterized by the ‘four Ds’: drooling, dysphagia, dysphonia, and
Family Centered Nursing for the Practical
Nurse Q&A with Rationale | Hondros
College of Nursing
1. A nurse is providing postpartum teaching to a client about fundal massage. What is the
primary purpose of this intervention?
A. To promote the production of breast milk
B. To decrease the risk of postpartum infection
C. To encourage the return of the menstrual cycle
D. To stimulate uterine contractions and prevent hemorrhage
Correct Answer: D
Rationale: Fundal massage is performed to ensure the uterus remains firm and contracted.
A boggy uterus indicates uterine atony, which is the leading cause of postpartum
hemorrhage. By massaging the fundus, the nurse helps expel clots and maintains muscle
tone to compress bleeding vessels.
2. An infant with hyperbilirubinemia is placed under phototherapy lights. Which nursing
action is a priority for this infant?
A. Apply lotion to the skin to prevent drying
B. Dress the infant in a t-shirt and diaper
,C. Limit fluid intake to prevent overhydration
D. Keep the infant’s eyes covered with opaque shields
Correct Answer: D
Rationale: Protecting the infant’s eyes is a critical safety measure during phototherapy to
prevent retinal damage. The infant should be unclothed, except for a diaper, to maximize
skin exposure to the light. The nurse must also monitor for dehydration and ensure the
infant receives adequate feedings to facilitate bilirubin excretion.
3. A nurse is assessing a 4-year-old child’s growth and development. According to Erikson,
which developmental stage is this child in?
A. Trust vs. Mistrust
B. Initiative vs. Guilt
C. Autonomy vs. Shame and Doubt
D. Industry vs. Inferiority
Correct Answer: B
Rationale: Preschoolers, aged 3 to 6 years, are in the stage of Initiative vs. Guilt. During
this time, they begin to assert power and control over the world through directing play and
other social interaction. If they are discouraged from doing so, they may develop a sense of
guilt regarding their desires.
, 4. Which clinical finding is most characteristic of a child diagnosed with pyloric stenosis?
A. Currant jelly-like stools
B. Bile-stained vomitus
C. Ribbon-like stools
D. Projectile vomiting after feedings
Correct Answer: D
Rationale: Pyloric stenosis involves a thickening of the pyloric sphincter, which creates an
obstruction. This leads to forceful, non-bile-stained projectile vomiting shortly after eating.
The nurse may also palpate an olive-shaped mass in the right upper quadrant of the
abdomen.
5. A nurse is caring for a child with epiglottitis. Which action should the nurse avoid?
A. Using a tongue blade to examine the throat
B. Administering humidified oxygen
C. Monitoring oxygen saturation
D. Keeping the child in an upright position
Correct Answer: A
Rationale: Visualizing the throat with a tongue blade or swab can trigger a laryngospasm
and cause complete airway obstruction in a child with epiglottitis. This condition is a
medical emergency characterized by the ‘four Ds’: drooling, dysphagia, dysphonia, and
