NUR 230 Exam 4 V1 | NUR 230 The
Childbearing / Child Caring Family | Q&A
with Rationale (NUR230 Exam 4) | Galen
College of Nursing
1. A nurse is assessing a client who is 4 hours postpartum and notes the fundus is firm, two
fingerbreadths above the umbilicus, and deviated to the right. Which of the following actions
should the nurse take?
A. Assist the client to the bathroom to void.
B. Massage the fundus vigorously.
C. Notify the provider of a possible hemorrhage.
D. Administer oxytocin as prescribed.
Answer: A
Rationale: A fundus that is displaced above the umbilicus and to the right is a classic sign
of bladder distention. The full bladder prevents the uterus from contracting effectively,
which increases the risk of hemorrhage. Assisting the client to void will allow the uterus to
return to the midline and descend properly.
,2. A nurse is providing discharge teaching to the parents of a newborn with
hyperbilirubinemia who is undergoing phototherapy at home. Which statement by a parent
indicates a need for further teaching?
A. I will keep the baby’s eyes covered while under the lights.
B. I will change the baby’s position every two hours.
C. I will monitor the number of wet diapers my baby has.
D. I will apply lotion to the baby’s skin to prevent drying.
Answer: D
Rationale: Ointments, lotions, or creams should never be applied to a newborn’s skin
during phototherapy because they can absorb heat and cause burns. Eye protection is
mandatory to prevent retinal damage from the lights. Frequent position changes and
monitoring output are essential components of safe phototherapy care.
3. A 2-year-old child with Tetralogy of Fallot becomes upset and suddenly turns blue with
rapid breathing. What is the priority nursing action?
A. Administer high-flow oxygen via mask.
B. Prepare for immediate endotracheal intubation.
C. Start a peripheral IV for fluid resuscitation.
D. Place the child in the knee-chest position.
Answer: D
, Rationale: This child is experiencing a hypercyanotic spell, often called a ‘tet spell.’ Placing
the child in a knee-chest position increases systemic vascular resistance, which decreases
the right-to-left shunt and improves pulmonary blood flow. This is the first-line
intervention before oxygen or medication administration.
4. A nurse is caring for a 4-year-old child suspected of having epiglottitis. Which of the
following actions is contraindicated?
A. Providing humidified oxygen.
B. Monitoring oxygen saturation levels.
C. Allowing the child to sit in a tripod position.
D. Assessing the throat with a tongue blade.
Answer: D
Rationale: Attempting to visualize the throat or using a tongue blade in a child with
suspected epiglottitis can trigger a laryngospasm and complete airway obstruction. The
diagnosis is usually confirmed via lateral neck X-ray. The nurse should keep the child calm
and prepared for emergency intubation.
5. Which clinical manifestation should a nurse expect to find in an infant diagnosed with
pyloric stenosis?
A. Projectile vomiting after feedings.
B. Bile-stained emesis.
C. Currant jelly-like stools.
Childbearing / Child Caring Family | Q&A
with Rationale (NUR230 Exam 4) | Galen
College of Nursing
1. A nurse is assessing a client who is 4 hours postpartum and notes the fundus is firm, two
fingerbreadths above the umbilicus, and deviated to the right. Which of the following actions
should the nurse take?
A. Assist the client to the bathroom to void.
B. Massage the fundus vigorously.
C. Notify the provider of a possible hemorrhage.
D. Administer oxytocin as prescribed.
Answer: A
Rationale: A fundus that is displaced above the umbilicus and to the right is a classic sign
of bladder distention. The full bladder prevents the uterus from contracting effectively,
which increases the risk of hemorrhage. Assisting the client to void will allow the uterus to
return to the midline and descend properly.
,2. A nurse is providing discharge teaching to the parents of a newborn with
hyperbilirubinemia who is undergoing phototherapy at home. Which statement by a parent
indicates a need for further teaching?
A. I will keep the baby’s eyes covered while under the lights.
B. I will change the baby’s position every two hours.
C. I will monitor the number of wet diapers my baby has.
D. I will apply lotion to the baby’s skin to prevent drying.
Answer: D
Rationale: Ointments, lotions, or creams should never be applied to a newborn’s skin
during phototherapy because they can absorb heat and cause burns. Eye protection is
mandatory to prevent retinal damage from the lights. Frequent position changes and
monitoring output are essential components of safe phototherapy care.
3. A 2-year-old child with Tetralogy of Fallot becomes upset and suddenly turns blue with
rapid breathing. What is the priority nursing action?
A. Administer high-flow oxygen via mask.
B. Prepare for immediate endotracheal intubation.
C. Start a peripheral IV for fluid resuscitation.
D. Place the child in the knee-chest position.
Answer: D
, Rationale: This child is experiencing a hypercyanotic spell, often called a ‘tet spell.’ Placing
the child in a knee-chest position increases systemic vascular resistance, which decreases
the right-to-left shunt and improves pulmonary blood flow. This is the first-line
intervention before oxygen or medication administration.
4. A nurse is caring for a 4-year-old child suspected of having epiglottitis. Which of the
following actions is contraindicated?
A. Providing humidified oxygen.
B. Monitoring oxygen saturation levels.
C. Allowing the child to sit in a tripod position.
D. Assessing the throat with a tongue blade.
Answer: D
Rationale: Attempting to visualize the throat or using a tongue blade in a child with
suspected epiglottitis can trigger a laryngospasm and complete airway obstruction. The
diagnosis is usually confirmed via lateral neck X-ray. The nurse should keep the child calm
and prepared for emergency intubation.
5. Which clinical manifestation should a nurse expect to find in an infant diagnosed with
pyloric stenosis?
A. Projectile vomiting after feedings.
B. Bile-stained emesis.
C. Currant jelly-like stools.
