NUR 230 Exam 3 V3 | NUR 230 The
Childbearing / Child Caring Family | Q&A
with Rationale (NUR230 Exam 3) | Galen
College of Nursing
1. A nurse is assessing a postpartum client who is experiencing heavy vaginal bleeding. Which
is the priority nursing action for uterine atony?
A. Perform fundal massage until firm
B. Administer oxygen via non-rebreather mask
C. Insert a second large-bore IV line
D. Prepare the client for a stat hysterectomy
Answer: A
Rationale: The initial and most important action for uterine atony is to perform fundal
massage to stimulate the uterus to contract. Fundal massage helps express clots and
promotes uterine firmness, which effectively stops excessive bleeding. If the uterus
remains boggy after massage, pharmacological interventions like oxytocin may be
required.
2. A newborn at 1 minute of life has a heart rate of 110 bpm, a weak cry, some flexion of the
extremities, grimacing when stimulated, and a pink body with blue extremities. What is the
APGAR score?
A. 5
,B. 8
C. 7
D. 6
Answer: D
Rationale: The score is calculated as 2 for heart rate (>100), 1 for respiratory effort (weak
cry), 1 for muscle tone (some flexion), 1 for reflex irritability (grimace), and 1 for color
(acrocyanosis). This results in a total APGAR score of 6, which indicates the need for close
observation. Accurate APGAR scoring is essential to determine if neonatal resuscitation is
immediately necessary.
3. A patient at 32 weeks gestation is receiving Magnesium Sulfate for preeclampsia. Which
finding should the nurse report to the provider immediately?
A. Urine output of 40 mL per hour
B. Deep tendon reflexes of 2+
C. Respiratory rate of 10 breaths per minute
D. Patient reports feeling warm and flushed
Answer: C
Rationale: A respiratory rate below 12 per minute is a critical sign of magnesium sulfate
toxicity and must be reported immediately. The nurse should also monitor for absent deep
, tendon reflexes and a significant drop in urine output. Calcium gluconate is the standard
antidote that must be kept at the bedside during magnesium administration.
4. The nurse is teaching a parent about the dietary management of a child with Celiac
disease. Which food choice indicates the parent understands the teaching?
A. Whole wheat bread
B. Barley soup
C. Rice cakes
D. Rye crackers
Answer: C
Rationale: Celiac disease requires a strict gluten-free diet, which excludes wheat, barley,
rye, and most oats. Rice is a safe, gluten-free alternative that the child can consume without
causing intestinal damage. Education for the family must emphasize reading labels for
hidden gluten in processed foods.
5. A 2-year-old child is admitted with a barking cough and stridor. Which diagnosis is most
likely associated with these symptoms?
A. Bronchiolitis
B. Epiglottitis
C. Laryngotracheobronchitis (Croup)
D. Cystic Fibrosis
Childbearing / Child Caring Family | Q&A
with Rationale (NUR230 Exam 3) | Galen
College of Nursing
1. A nurse is assessing a postpartum client who is experiencing heavy vaginal bleeding. Which
is the priority nursing action for uterine atony?
A. Perform fundal massage until firm
B. Administer oxygen via non-rebreather mask
C. Insert a second large-bore IV line
D. Prepare the client for a stat hysterectomy
Answer: A
Rationale: The initial and most important action for uterine atony is to perform fundal
massage to stimulate the uterus to contract. Fundal massage helps express clots and
promotes uterine firmness, which effectively stops excessive bleeding. If the uterus
remains boggy after massage, pharmacological interventions like oxytocin may be
required.
2. A newborn at 1 minute of life has a heart rate of 110 bpm, a weak cry, some flexion of the
extremities, grimacing when stimulated, and a pink body with blue extremities. What is the
APGAR score?
A. 5
,B. 8
C. 7
D. 6
Answer: D
Rationale: The score is calculated as 2 for heart rate (>100), 1 for respiratory effort (weak
cry), 1 for muscle tone (some flexion), 1 for reflex irritability (grimace), and 1 for color
(acrocyanosis). This results in a total APGAR score of 6, which indicates the need for close
observation. Accurate APGAR scoring is essential to determine if neonatal resuscitation is
immediately necessary.
3. A patient at 32 weeks gestation is receiving Magnesium Sulfate for preeclampsia. Which
finding should the nurse report to the provider immediately?
A. Urine output of 40 mL per hour
B. Deep tendon reflexes of 2+
C. Respiratory rate of 10 breaths per minute
D. Patient reports feeling warm and flushed
Answer: C
Rationale: A respiratory rate below 12 per minute is a critical sign of magnesium sulfate
toxicity and must be reported immediately. The nurse should also monitor for absent deep
, tendon reflexes and a significant drop in urine output. Calcium gluconate is the standard
antidote that must be kept at the bedside during magnesium administration.
4. The nurse is teaching a parent about the dietary management of a child with Celiac
disease. Which food choice indicates the parent understands the teaching?
A. Whole wheat bread
B. Barley soup
C. Rice cakes
D. Rye crackers
Answer: C
Rationale: Celiac disease requires a strict gluten-free diet, which excludes wheat, barley,
rye, and most oats. Rice is a safe, gluten-free alternative that the child can consume without
causing intestinal damage. Education for the family must emphasize reading labels for
hidden gluten in processed foods.
5. A 2-year-old child is admitted with a barking cough and stridor. Which diagnosis is most
likely associated with these symptoms?
A. Bronchiolitis
B. Epiglottitis
C. Laryngotracheobronchitis (Croup)
D. Cystic Fibrosis
