NUR 254 Exam 1: Maternal and Pediatrics - Galen College
of Nursing Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is assessing a client at 34 weeks gestation who reports a sudden onset of sharp abdominal pain
and vaginal bleeding. The nurse notes the abdomen is board-like and tender upon palpation. Which
condition should the nurse suspect?
A. Placenta previa
B. Ectopic pregnancy
C. Hydatidiform mole
D. Abruptio placentae
Correct Answer: D
Rationale: Abruptio placentae is characterized by the premature separation of the placenta from the
uterine wall, leading to painful bleeding and uterine rigidity. The board-like abdomen occurs because
blood infiltrates the uterine musculature, causing significant irritation and tension. This condition is a
medical emergency that requires immediate intervention to save both the mother and the fetus. Placenta
previa is typically associated with painless bleeding, which helps differentiate the two conditions. The
nurse must prioritize monitoring vital signs and preparing for a potential emergency cesarean section.
2. A nurse is caring for a 4-year-old child scheduled for a procedure. According to Erikson’s stages of
psychosocial development, which task is this child attempting to master?
A. Autonomy vs. Shame and Doubt
B. Trust vs. Mistrust
C. Industry vs. Inferiority
,D. Initiative vs. Guilt
Correct Answer: D
Rationale: Children in the preschool years, aged 3 to 6, are navigating the developmental stage of
initiative versus guilt. During this time, they begin to assert power and control over their environment
through play and social interactions. If they are encouraged to explore, they develop a sense of purpose
and initiative. Conversely, if their efforts are criticized or controlled too strictly, they may develop a sense
of guilt. The nurse should support this stage by allowing the child to make simple choices about their
care.
3. A client in labor is receiving a continuous intravenous infusion of magnesium sulfate for preeclampsia.
Which finding should the nurse identify as a sign of magnesium toxicity?
A. Hyperreflexia of deep tendons
B. Increased urinary output
C. Respiratory rate of 10 breaths per minute
D. Blood pressure of 150/95 mmHg
Correct Answer: C
Rationale: Magnesium sulfate is a central nervous system depressant used to prevent seizures in clients
with preeclampsia. A respiratory rate below 12 breaths per minute is a critical indicator of magnesium
toxicity and impending respiratory arrest. The nurse should also monitor for the loss of deep tendon
reflexes, which typically precedes respiratory depression. If toxicity is suspected, the infusion must be
stopped immediately and the healthcare provider notified. Calcium gluconate is the standard antidote
that should be kept readily available at the bedside.
, 4. A nurse is assessing a newborn 1 minute after birth and finds the following: heart rate 110/min, slow and
irregular respirations, some flexion of extremities, grimace in response to suctioning, and a pink body with
blue extremities. What is the Apgar score?
A. 6
B. 5
C. 7
D. 8
Correct Answer: A
Rationale: The Apgar score is calculated by awarding points for five clinical signs: heart rate, respiratory
effort, muscle tone, reflex irritability, and color. This newborn receives 2 points for heart rate (>100), 1
point for slow/irregular respirations, 1 point for some flexion, 1 point for a grimace, and 1 point for
acrocyanosis. Summing these values results in a total Apgar score of 6, indicating a need for some
resuscitation and close observation. Monitoring the newborn’s transition to extrauterine life is essential
during the first minutes after delivery. Scores between 4 and 6 suggest moderate distress that requires
immediate nursing interventions.
5. Which of the following interventions is a priority for a 2-year-old child admitted with suspected
epiglottitis?
A. Prepare for emergency airway management
B. Place the child in a supine position for easier breathing
C. Obtain a throat culture to identify the pathogen
D. Assess the throat using a tongue blade
Correct Answer: A
of Nursing Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is assessing a client at 34 weeks gestation who reports a sudden onset of sharp abdominal pain
and vaginal bleeding. The nurse notes the abdomen is board-like and tender upon palpation. Which
condition should the nurse suspect?
A. Placenta previa
B. Ectopic pregnancy
C. Hydatidiform mole
D. Abruptio placentae
Correct Answer: D
Rationale: Abruptio placentae is characterized by the premature separation of the placenta from the
uterine wall, leading to painful bleeding and uterine rigidity. The board-like abdomen occurs because
blood infiltrates the uterine musculature, causing significant irritation and tension. This condition is a
medical emergency that requires immediate intervention to save both the mother and the fetus. Placenta
previa is typically associated with painless bleeding, which helps differentiate the two conditions. The
nurse must prioritize monitoring vital signs and preparing for a potential emergency cesarean section.
2. A nurse is caring for a 4-year-old child scheduled for a procedure. According to Erikson’s stages of
psychosocial development, which task is this child attempting to master?
A. Autonomy vs. Shame and Doubt
B. Trust vs. Mistrust
C. Industry vs. Inferiority
,D. Initiative vs. Guilt
Correct Answer: D
Rationale: Children in the preschool years, aged 3 to 6, are navigating the developmental stage of
initiative versus guilt. During this time, they begin to assert power and control over their environment
through play and social interactions. If they are encouraged to explore, they develop a sense of purpose
and initiative. Conversely, if their efforts are criticized or controlled too strictly, they may develop a sense
of guilt. The nurse should support this stage by allowing the child to make simple choices about their
care.
3. A client in labor is receiving a continuous intravenous infusion of magnesium sulfate for preeclampsia.
Which finding should the nurse identify as a sign of magnesium toxicity?
A. Hyperreflexia of deep tendons
B. Increased urinary output
C. Respiratory rate of 10 breaths per minute
D. Blood pressure of 150/95 mmHg
Correct Answer: C
Rationale: Magnesium sulfate is a central nervous system depressant used to prevent seizures in clients
with preeclampsia. A respiratory rate below 12 breaths per minute is a critical indicator of magnesium
toxicity and impending respiratory arrest. The nurse should also monitor for the loss of deep tendon
reflexes, which typically precedes respiratory depression. If toxicity is suspected, the infusion must be
stopped immediately and the healthcare provider notified. Calcium gluconate is the standard antidote
that should be kept readily available at the bedside.
, 4. A nurse is assessing a newborn 1 minute after birth and finds the following: heart rate 110/min, slow and
irregular respirations, some flexion of extremities, grimace in response to suctioning, and a pink body with
blue extremities. What is the Apgar score?
A. 6
B. 5
C. 7
D. 8
Correct Answer: A
Rationale: The Apgar score is calculated by awarding points for five clinical signs: heart rate, respiratory
effort, muscle tone, reflex irritability, and color. This newborn receives 2 points for heart rate (>100), 1
point for slow/irregular respirations, 1 point for some flexion, 1 point for a grimace, and 1 point for
acrocyanosis. Summing these values results in a total Apgar score of 6, indicating a need for some
resuscitation and close observation. Monitoring the newborn’s transition to extrauterine life is essential
during the first minutes after delivery. Scores between 4 and 6 suggest moderate distress that requires
immediate nursing interventions.
5. Which of the following interventions is a priority for a 2-year-old child admitted with suspected
epiglottitis?
A. Prepare for emergency airway management
B. Place the child in a supine position for easier breathing
C. Obtain a throat culture to identify the pathogen
D. Assess the throat using a tongue blade
Correct Answer: A
