NUR 230 Exam 3 V2 | NUR 230 The
Childbearing / Child Caring Family | Q&A
with Rationale (NUR230 Exam 3) | Galen
College of Nursing
1. A nurse is assessing a client at 34 weeks of gestation who presents with sudden, painless
vaginal bleeding. Which of the following conditions should the nurse suspect?
A. Abruptio placentae
B. Placenta previa
C. Preterm labor
D. Uterine rupture
Answer: B
Rationale: Placenta previa typically manifests as painless, bright red vaginal bleeding
during the second or third trimester. This occurs when the placenta covers the internal
cervical os partially or completely. In contrast, abruptio placentae involves painful bleeding
and uterine tenderness.
2. A nurse is caring for a 4-year-old child following a tonsillectomy. Which of the following
findings should the nurse identify as a priority to report to the provider?
A. Dark brown secretions in the mouth
B. Report of a sore throat
,C. Frequent swallowing
D. A low-grade fever of 37.8 C (100 F)
Answer: C
Rationale: Frequent swallowing is a classic sign of post-operative bleeding following a
tonsillectomy as the child is attempting to clear the throat of blood. This requires
immediate assessment of the surgical site and notification of the surgeon to prevent
hemorrhage. Dark brown secretions are normal from old blood, and pain is expected post-
operatively.
3. Which of the following interventions is the priority for a nurse caring for an infant with
bronchiolitis caused by Respiratory Syncytial Virus (RSV)?
A. Administering oral antibiotics
B. Providing a high-protein diet
C. Implementing contact precautions
D. Administering chest physiotherapy
Answer: C
Rationale: RSV is highly contagious and is primarily spread through direct contact with
secretions or contaminated surfaces. Implementing contact precautions is the priority to
prevent the spread of the virus to other patients and staff. Antibiotics are not used for viral
infections, and chest physiotherapy is generally not recommended for bronchiolitis.
, 4. A nurse is assessing a postpartum client 2 hours after delivery. The fundus is displaced to
the right and is above the umbilicus. Which of the following actions should the nurse take?
A. Perform fundal massage
B. Administer oxytocin as prescribed
C. Assist the client to the bathroom to void
D. Notify the provider immediately
Answer: C
Rationale: A fundus that is displaced to the side and elevated above the umbilicus typically
indicates a full bladder. A full bladder prevents the uterus from contracting effectively,
which increases the risk of postpartum hemorrhage. Assisting the client to void should
resolve the displacement and allow the fundus to return to the midline.
5. A child is admitted with a diagnosis of Intussusception. Which of the following stool
characteristics should the nurse expect to observe?
A. Stools mixed with blood and mucus (currant jelly)
B. Steatorrhea (fatty, oily stools)
C. Ribbon-like, foul-smelling stools
D. Hard, pebble-like stools
Answer: A
Childbearing / Child Caring Family | Q&A
with Rationale (NUR230 Exam 3) | Galen
College of Nursing
1. A nurse is assessing a client at 34 weeks of gestation who presents with sudden, painless
vaginal bleeding. Which of the following conditions should the nurse suspect?
A. Abruptio placentae
B. Placenta previa
C. Preterm labor
D. Uterine rupture
Answer: B
Rationale: Placenta previa typically manifests as painless, bright red vaginal bleeding
during the second or third trimester. This occurs when the placenta covers the internal
cervical os partially or completely. In contrast, abruptio placentae involves painful bleeding
and uterine tenderness.
2. A nurse is caring for a 4-year-old child following a tonsillectomy. Which of the following
findings should the nurse identify as a priority to report to the provider?
A. Dark brown secretions in the mouth
B. Report of a sore throat
,C. Frequent swallowing
D. A low-grade fever of 37.8 C (100 F)
Answer: C
Rationale: Frequent swallowing is a classic sign of post-operative bleeding following a
tonsillectomy as the child is attempting to clear the throat of blood. This requires
immediate assessment of the surgical site and notification of the surgeon to prevent
hemorrhage. Dark brown secretions are normal from old blood, and pain is expected post-
operatively.
3. Which of the following interventions is the priority for a nurse caring for an infant with
bronchiolitis caused by Respiratory Syncytial Virus (RSV)?
A. Administering oral antibiotics
B. Providing a high-protein diet
C. Implementing contact precautions
D. Administering chest physiotherapy
Answer: C
Rationale: RSV is highly contagious and is primarily spread through direct contact with
secretions or contaminated surfaces. Implementing contact precautions is the priority to
prevent the spread of the virus to other patients and staff. Antibiotics are not used for viral
infections, and chest physiotherapy is generally not recommended for bronchiolitis.
, 4. A nurse is assessing a postpartum client 2 hours after delivery. The fundus is displaced to
the right and is above the umbilicus. Which of the following actions should the nurse take?
A. Perform fundal massage
B. Administer oxytocin as prescribed
C. Assist the client to the bathroom to void
D. Notify the provider immediately
Answer: C
Rationale: A fundus that is displaced to the side and elevated above the umbilicus typically
indicates a full bladder. A full bladder prevents the uterus from contracting effectively,
which increases the risk of postpartum hemorrhage. Assisting the client to void should
resolve the displacement and allow the fundus to return to the midline.
5. A child is admitted with a diagnosis of Intussusception. Which of the following stool
characteristics should the nurse expect to observe?
A. Stools mixed with blood and mucus (currant jelly)
B. Steatorrhea (fatty, oily stools)
C. Ribbon-like, foul-smelling stools
D. Hard, pebble-like stools
Answer: A
