NUR 254 Exam 4 Practice Exam
Questions And Correct Answers (Verified
Answers) Plus Rationales 2026 Q&A
Instant Download Pdf
1. A postpartum client is assessed 12 hours after a vaginal delivery. Which
finding requires immediate nursing intervention?
A. Fundus firm and midline
B. Moderate lochia rubra
C. Boggy uterus displaced to the right
D. Temperature of 99.1°F (37.3°C)
Answer: Boggy uterus displaced to the right
Rationale: A boggy uterus suggests uterine atony, a leading cause of postpartum
hemorrhage. Displacement to the right often indicates a full bladder, which
prevents effective uterine contraction. The nurse should assist the client to void
and reassess the fundus.
2. A nurse is teaching a pregnant client about the purpose of folic acid
supplementation. Which statement by the client indicates understanding?
A. It prevents iron-deficiency anemia.
B. It strengthens fetal bones.
,C. It reduces the risk of neural tube defects.
D. It prevents gestational diabetes.
Answer: It reduces the risk of neural tube defects.
Rationale: Folic acid is essential before conception and during early pregnancy
to reduce the risk of neural tube defects such as spina bifida.
3. A newborn has an Apgar score of 8 at one minute. Which interpretation is
correct?
A. Immediate resuscitation is required.
B. The newborn has severe respiratory distress.
C. The newborn is adapting well to extrauterine life.
D. The newborn requires intubation.
Answer: The newborn is adapting well to extrauterine life.
Rationale: An Apgar score of 7–10 indicates normal adaptation and generally
requires only routine newborn care.
4. A nurse is caring for a child with dehydration from gastroenteritis. Which
assessment finding indicates moderate dehydration?
A. Bradycardia
B. Dry mucous membranes
C. Hypertension
D. Bounding pulses
Answer: Dry mucous membranes
Rationale: Dry mucous membranes are a classic sign of moderate dehydration.
Bradycardia and hypotension are usually late findings associated with severe
dehydration.
5. A child with acute otitis media is prescribed amoxicillin. Which instruction
should the nurse provide?
A. Stop the medication when symptoms improve.
B. Give only at bedtime.
,C. Complete the entire prescribed course.
D. Double the dose if one is missed.
Answer: Complete the entire prescribed course.
Rationale: Completing the prescribed antibiotic course helps eradicate infection
and reduces the risk of antibiotic resistance.
6. Which assessment finding in a newborn requires immediate notification of
the healthcare provider?
A. Acrocyanosis
B. Respiratory rate of 42 breaths/min
C. Central cyanosis
D. Heart rate of 130 beats/min
Answer: Central cyanosis
Rationale: Central cyanosis indicates inadequate oxygenation and requires
immediate evaluation and intervention.
7. Which finding is expected during the first stage of labor?
A. Delivery of the placenta
B. Birth of the infant
C. Progressive cervical dilation and effacement
D. Maternal stabilization after delivery
Answer: Progressive cervical dilation and effacement
Rationale: The first stage of labor begins with regular contractions and ends
with complete cervical dilation (10 cm).
8. Which immunization is routinely administered shortly after birth?
A. MMR
B. Varicella
C. Hepatitis B vaccine
D. DTaP
, Answer: Hepatitis B vaccine
Rationale: The first dose of the hepatitis B vaccine is routinely given within 24
hours of birth unless contraindicated.
9. A nurse is assessing a toddler. Which behavior is developmentally
appropriate?
A. Solves complex math problems
B. Writes complete sentences
C. Uses two-word phrases
D. Reads independently
Answer: Uses two-word phrases
Rationale: Toddlers typically begin using two-word phrases around 2 years of
age as language develops.
10.Which finding is most concerning in a client with preeclampsia?
A. Mild edema
B. Blood pressure 138/88 mm Hg
C. Hyperreflexia with clonus
D. Weight gain of 2 lb in one week
Answer: Hyperreflexia with clonus
Rationale: Hyperreflexia and clonus suggest worsening preeclampsia and
increased risk for seizures (eclampsia), requiring immediate intervention.
11.A nurse is caring for a child with asthma. Which assessment finding
indicates worsening respiratory status?
A. Productive cough
B. Silent chest on auscultation
C. Mild wheezing
D. Respiratory rate of 24/min
Answer: Silent chest on auscultation
Questions And Correct Answers (Verified
Answers) Plus Rationales 2026 Q&A
Instant Download Pdf
1. A postpartum client is assessed 12 hours after a vaginal delivery. Which
finding requires immediate nursing intervention?
A. Fundus firm and midline
B. Moderate lochia rubra
C. Boggy uterus displaced to the right
D. Temperature of 99.1°F (37.3°C)
Answer: Boggy uterus displaced to the right
Rationale: A boggy uterus suggests uterine atony, a leading cause of postpartum
hemorrhage. Displacement to the right often indicates a full bladder, which
prevents effective uterine contraction. The nurse should assist the client to void
and reassess the fundus.
2. A nurse is teaching a pregnant client about the purpose of folic acid
supplementation. Which statement by the client indicates understanding?
A. It prevents iron-deficiency anemia.
B. It strengthens fetal bones.
,C. It reduces the risk of neural tube defects.
D. It prevents gestational diabetes.
Answer: It reduces the risk of neural tube defects.
Rationale: Folic acid is essential before conception and during early pregnancy
to reduce the risk of neural tube defects such as spina bifida.
3. A newborn has an Apgar score of 8 at one minute. Which interpretation is
correct?
A. Immediate resuscitation is required.
B. The newborn has severe respiratory distress.
C. The newborn is adapting well to extrauterine life.
D. The newborn requires intubation.
Answer: The newborn is adapting well to extrauterine life.
Rationale: An Apgar score of 7–10 indicates normal adaptation and generally
requires only routine newborn care.
4. A nurse is caring for a child with dehydration from gastroenteritis. Which
assessment finding indicates moderate dehydration?
A. Bradycardia
B. Dry mucous membranes
C. Hypertension
D. Bounding pulses
Answer: Dry mucous membranes
Rationale: Dry mucous membranes are a classic sign of moderate dehydration.
Bradycardia and hypotension are usually late findings associated with severe
dehydration.
5. A child with acute otitis media is prescribed amoxicillin. Which instruction
should the nurse provide?
A. Stop the medication when symptoms improve.
B. Give only at bedtime.
,C. Complete the entire prescribed course.
D. Double the dose if one is missed.
Answer: Complete the entire prescribed course.
Rationale: Completing the prescribed antibiotic course helps eradicate infection
and reduces the risk of antibiotic resistance.
6. Which assessment finding in a newborn requires immediate notification of
the healthcare provider?
A. Acrocyanosis
B. Respiratory rate of 42 breaths/min
C. Central cyanosis
D. Heart rate of 130 beats/min
Answer: Central cyanosis
Rationale: Central cyanosis indicates inadequate oxygenation and requires
immediate evaluation and intervention.
7. Which finding is expected during the first stage of labor?
A. Delivery of the placenta
B. Birth of the infant
C. Progressive cervical dilation and effacement
D. Maternal stabilization after delivery
Answer: Progressive cervical dilation and effacement
Rationale: The first stage of labor begins with regular contractions and ends
with complete cervical dilation (10 cm).
8. Which immunization is routinely administered shortly after birth?
A. MMR
B. Varicella
C. Hepatitis B vaccine
D. DTaP
, Answer: Hepatitis B vaccine
Rationale: The first dose of the hepatitis B vaccine is routinely given within 24
hours of birth unless contraindicated.
9. A nurse is assessing a toddler. Which behavior is developmentally
appropriate?
A. Solves complex math problems
B. Writes complete sentences
C. Uses two-word phrases
D. Reads independently
Answer: Uses two-word phrases
Rationale: Toddlers typically begin using two-word phrases around 2 years of
age as language develops.
10.Which finding is most concerning in a client with preeclampsia?
A. Mild edema
B. Blood pressure 138/88 mm Hg
C. Hyperreflexia with clonus
D. Weight gain of 2 lb in one week
Answer: Hyperreflexia with clonus
Rationale: Hyperreflexia and clonus suggest worsening preeclampsia and
increased risk for seizures (eclampsia), requiring immediate intervention.
11.A nurse is caring for a child with asthma. Which assessment finding
indicates worsening respiratory status?
A. Productive cough
B. Silent chest on auscultation
C. Mild wheezing
D. Respiratory rate of 24/min
Answer: Silent chest on auscultation
