NUR 230 Exam 3 V1 | NUR 230 The
Childbearing / Child Caring Family | Q&A
with Rationale (NUR230 Exam 3) | Galen
College of Nursing
1. A nurse is assessing a newborn 1 minute after birth and finds a heart rate of 110/min, a
slow/weak cry, some flexion of the extremities, a grimace when stimulated, and a pink body
with blue extremities. What APGAR score should the nurse assign?
A. 5
B. 6
C. 7
D. 8
Answer: B
Rationale: The APGAR score is calculated based on five criteria. The heart rate over 100
grants 2 points, the slow cry grants 1 point, some flexion grants 1 point, the grimace grants
1 point, and acrocyanosis (pink body/blue extremities) grants 1 point. This total equals 6,
which indicates the newborn requires some assistance and close observation during the
transition to extrauterine life.
,2. A nurse is caring for a client who is at 34 weeks of gestation and has a prescription for
magnesium sulfate IV to treat preeclampsia. Which of the following findings should the nurse
identify as a sign of magnesium toxicity?
A. Hyperreflexia
B. Increased urinary output
C. Respiratory rate of 10/min
D. Tachycardia
Answer: C
Rationale: Magnesium sulfate is a central nervous system depressant used to prevent
seizures in preeclamptic patients. A respiratory rate below 12/min is a classic sign of
toxicity and indicates the need for immediate cessation of the infusion. The nurse must also
monitor for decreased deep tendon reflexes and oliguria as additional indicators of toxic
levels.
3. A nurse is providing postpartum teaching to a client who is non-lactating. Which of the
following instructions should the nurse include to help suppress lactation?
A. Apply warm compresses to the breasts twice daily.
B. Wear a well-fitted supportive bra continuously.
C. Express small amounts of milk if the breasts feel full.
D. Stimulate the nipples during showering.
,Answer: B
Rationale: Continuous use of a supportive bra helps provide compression and reduces
breast engorgement in non-lactating clients. Clients should avoid nipple stimulation and
heat, as these actions promote milk production. Applying cold cabbage leaves or ice packs
is recommended to reduce swelling and discomfort during the suppression process.
4. A nurse is assessing a child who has Tetralogy of Fallot. Which of the following clinical
manifestations should the nurse expect?
A. Cyanosis and clubbing of fingers
B. Left-to-right shunting of blood
C. Increased pulmonary blood flow
D. Bounding peripheral pulses
Answer: A
Rationale: Tetralogy of Fallot is a cyanotic heart defect characterized by decreased
pulmonary blood flow and right-to-left shunting. Chronic hypoxia leads to clinical
manifestations such as cyanosis, polycythemia, and digital clubbing. Hypercyanotic spells,
often called ‘tet spells,’ occur when oxygen demands exceed the supply during activities
like crying or feeding.
5. A nurse is caring for a 2-year-old child who has laryngotracheobronchitis (croup). Which of
the following assessments is the priority?
A. Assessing the child’s skin turgor
, B. Measuring the child’s temperature
C. Observing for stridor and retractions
D. Checking the child’s capillary refill time
Answer: C
Rationale: Airway management is the highest priority for a child with croup due to the risk
of upper airway obstruction. Stridor and intercostal retractions are significant indicators of
respiratory distress that require immediate intervention. The nurse must maintain a patent
airway and monitor oxygen saturation to ensure adequate ventilation.
6. A nurse is assessing a client who is 2 hours postpartum and has a boggy fundus displaced to
the right of the midline. What is the nurse’s priority action?
A. Administer oxytocin IV.
B. Perform a fundal massage.
C. Assist the client to the bathroom to void.
D. Place the client in the Trendelenburg position.
Answer: C
Rationale: A fundus that is displaced to the right and is boggy usually indicates a distended
bladder. A full bladder prevents the uterus from contracting efficiently, increasing the risk
of postpartum hemorrhage. Assisting the client to void allows the uterus to return to the
midline and contract properly.
Childbearing / Child Caring Family | Q&A
with Rationale (NUR230 Exam 3) | Galen
College of Nursing
1. A nurse is assessing a newborn 1 minute after birth and finds a heart rate of 110/min, a
slow/weak cry, some flexion of the extremities, a grimace when stimulated, and a pink body
with blue extremities. What APGAR score should the nurse assign?
A. 5
B. 6
C. 7
D. 8
Answer: B
Rationale: The APGAR score is calculated based on five criteria. The heart rate over 100
grants 2 points, the slow cry grants 1 point, some flexion grants 1 point, the grimace grants
1 point, and acrocyanosis (pink body/blue extremities) grants 1 point. This total equals 6,
which indicates the newborn requires some assistance and close observation during the
transition to extrauterine life.
,2. A nurse is caring for a client who is at 34 weeks of gestation and has a prescription for
magnesium sulfate IV to treat preeclampsia. Which of the following findings should the nurse
identify as a sign of magnesium toxicity?
A. Hyperreflexia
B. Increased urinary output
C. Respiratory rate of 10/min
D. Tachycardia
Answer: C
Rationale: Magnesium sulfate is a central nervous system depressant used to prevent
seizures in preeclamptic patients. A respiratory rate below 12/min is a classic sign of
toxicity and indicates the need for immediate cessation of the infusion. The nurse must also
monitor for decreased deep tendon reflexes and oliguria as additional indicators of toxic
levels.
3. A nurse is providing postpartum teaching to a client who is non-lactating. Which of the
following instructions should the nurse include to help suppress lactation?
A. Apply warm compresses to the breasts twice daily.
B. Wear a well-fitted supportive bra continuously.
C. Express small amounts of milk if the breasts feel full.
D. Stimulate the nipples during showering.
,Answer: B
Rationale: Continuous use of a supportive bra helps provide compression and reduces
breast engorgement in non-lactating clients. Clients should avoid nipple stimulation and
heat, as these actions promote milk production. Applying cold cabbage leaves or ice packs
is recommended to reduce swelling and discomfort during the suppression process.
4. A nurse is assessing a child who has Tetralogy of Fallot. Which of the following clinical
manifestations should the nurse expect?
A. Cyanosis and clubbing of fingers
B. Left-to-right shunting of blood
C. Increased pulmonary blood flow
D. Bounding peripheral pulses
Answer: A
Rationale: Tetralogy of Fallot is a cyanotic heart defect characterized by decreased
pulmonary blood flow and right-to-left shunting. Chronic hypoxia leads to clinical
manifestations such as cyanosis, polycythemia, and digital clubbing. Hypercyanotic spells,
often called ‘tet spells,’ occur when oxygen demands exceed the supply during activities
like crying or feeding.
5. A nurse is caring for a 2-year-old child who has laryngotracheobronchitis (croup). Which of
the following assessments is the priority?
A. Assessing the child’s skin turgor
, B. Measuring the child’s temperature
C. Observing for stridor and retractions
D. Checking the child’s capillary refill time
Answer: C
Rationale: Airway management is the highest priority for a child with croup due to the risk
of upper airway obstruction. Stridor and intercostal retractions are significant indicators of
respiratory distress that require immediate intervention. The nurse must maintain a patent
airway and monitor oxygen saturation to ensure adequate ventilation.
6. A nurse is assessing a client who is 2 hours postpartum and has a boggy fundus displaced to
the right of the midline. What is the nurse’s priority action?
A. Administer oxytocin IV.
B. Perform a fundal massage.
C. Assist the client to the bathroom to void.
D. Place the client in the Trendelenburg position.
Answer: C
Rationale: A fundus that is displaced to the right and is boggy usually indicates a distended
bladder. A full bladder prevents the uterus from contracting efficiently, increasing the risk
of postpartum hemorrhage. Assisting the client to void allows the uterus to return to the
midline and contract properly.
