NUR 254 Exam 3: Maternal and Pediatrics - Galen College
of Nursing Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is assessing a postpartum client 4 hours after delivery and finds the fundus to be boggy and
shifted to the right of the midline. What is the priority nursing action?
A. Massage the fundus until it becomes firm.
B. Notify the healthcare provider immediately.
C. Encourage the client to void or catheterize if necessary.
D. Increase the rate of intravenous oxytocin infusion.
Correct Answer: C
Rationale: A fundus that is shifted to the right usually indicates a distended bladder is pushing the uterus
out of place. Emptying the bladder allows the uterus to return to the midline and contract effectively.
While fundal massage is important for a boggy uterus, it will not resolve the displacement caused by the
bladder. If the fundus remains boggy after voiding, massage and medication should then be prioritized.
Consistent assessment of the bladder and fundus prevents complications such as postpartum
hemorrhage.
2. A newborn has an APGAR score of 9 at one minute. Which of the following is the most likely reason the
infant did not receive a perfect score?
A. The infant has a heart rate of 90 beats per minute.
B. The infant is exhibiting acrocyanosis.
C. The infant is crying weakly and shows some flexion.
D. The infant does not respond to a catheter in the nostril.
,Correct Answer: B
Rationale: Acrocyanosis, which is a bluish discoloration of the hands and feet, is a common and normal
finding in the first 24 hours of life. This condition results in a score of 1 for color rather than the
maximum score of 2. Most healthy newborns lose one point for color even if all other categories are
perfect. The remaining APGAR components include heart rate, reflex irritability, muscle tone, and
respiratory effort. Achieving a score of 9 indicates the newborn is in stable condition and adapting well to
extrauterine life.
3. A client at 34 weeks gestation presents with a blood pressure of 162/110 mmHg and 3+ proteinuria.
Which medication should the nurse anticipate administering to prevent seizures?
A. Nifedipine
B. Labetalol
C. Magnesium sulfate
D. Hydralazine
Correct Answer: C
Rationale: Magnesium sulfate is the primary medication used in preeclampsia to provide
neuroprotection and prevent eclampsia seizures. It acts as a central nervous system depressant and
relaxes smooth muscle. While Nifedipine and Labetalol are used to manage blood pressure, they do not
provide the same seizure prophylaxis. The nurse must monitor for magnesium toxicity by checking deep
tendon reflexes and respiratory rate. Ensuring the availability of calcium gluconate is essential as it
serves as the antidote for magnesium toxicity.
4. A nurse is providing discharge teaching to a mother whose infant was treated with phototherapy for
hyperbilirubinemia. Which statement by the mother indicates a need for further teaching?
A. I will continue to breastfeed my baby every 2 to 3 hours.
, B. I will keep my baby’s skin well-hydrated by applying lotion.
C. I will monitor the number of wet and dirty diapers my baby has.
D. I will check my baby’s skin color in natural light.
Correct Answer: B
Rationale: Lotion or oils should never be applied to a baby’s skin during phototherapy because they can
cause burns under the lights. Maintaining hydration through frequent breastfeeding is critical to help the
baby excrete bilirubin through stools and urine. The mother should monitor diaper counts to ensure the
infant is receiving adequate fluids. Checking the skin in natural light provides the most accurate
assessment of jaundice levels. Teaching these safety measures helps prevent skin damage and ensures
effective treatment of hyperbilirubinemia.
5. A 2-year-old child is brought to the emergency department with suspected epiglottitis. Which action
should the nurse avoid performing?
A. Attempting to visualize the throat with a tongue depressor.
B. Providing humidified oxygen via a mask.
C. Encouraging the child to sit in a tripod position.
D. Keeping the child as calm and quiet as possible.
Correct Answer: A
Rationale: Using a tongue depressor or any instrument in the throat of a child with suspected epiglottitis
can trigger a fatal laryngospasm. The nurse must avoid invasive assessments until an artificial airway can
be established by an expert team. Epiglottitis is a medical emergency characterized by a high fever,
drooling, and respiratory distress. Sitting in a tripod position helps the child maintain a patent airway by
of Nursing Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is assessing a postpartum client 4 hours after delivery and finds the fundus to be boggy and
shifted to the right of the midline. What is the priority nursing action?
A. Massage the fundus until it becomes firm.
B. Notify the healthcare provider immediately.
C. Encourage the client to void or catheterize if necessary.
D. Increase the rate of intravenous oxytocin infusion.
Correct Answer: C
Rationale: A fundus that is shifted to the right usually indicates a distended bladder is pushing the uterus
out of place. Emptying the bladder allows the uterus to return to the midline and contract effectively.
While fundal massage is important for a boggy uterus, it will not resolve the displacement caused by the
bladder. If the fundus remains boggy after voiding, massage and medication should then be prioritized.
Consistent assessment of the bladder and fundus prevents complications such as postpartum
hemorrhage.
2. A newborn has an APGAR score of 9 at one minute. Which of the following is the most likely reason the
infant did not receive a perfect score?
A. The infant has a heart rate of 90 beats per minute.
B. The infant is exhibiting acrocyanosis.
C. The infant is crying weakly and shows some flexion.
D. The infant does not respond to a catheter in the nostril.
,Correct Answer: B
Rationale: Acrocyanosis, which is a bluish discoloration of the hands and feet, is a common and normal
finding in the first 24 hours of life. This condition results in a score of 1 for color rather than the
maximum score of 2. Most healthy newborns lose one point for color even if all other categories are
perfect. The remaining APGAR components include heart rate, reflex irritability, muscle tone, and
respiratory effort. Achieving a score of 9 indicates the newborn is in stable condition and adapting well to
extrauterine life.
3. A client at 34 weeks gestation presents with a blood pressure of 162/110 mmHg and 3+ proteinuria.
Which medication should the nurse anticipate administering to prevent seizures?
A. Nifedipine
B. Labetalol
C. Magnesium sulfate
D. Hydralazine
Correct Answer: C
Rationale: Magnesium sulfate is the primary medication used in preeclampsia to provide
neuroprotection and prevent eclampsia seizures. It acts as a central nervous system depressant and
relaxes smooth muscle. While Nifedipine and Labetalol are used to manage blood pressure, they do not
provide the same seizure prophylaxis. The nurse must monitor for magnesium toxicity by checking deep
tendon reflexes and respiratory rate. Ensuring the availability of calcium gluconate is essential as it
serves as the antidote for magnesium toxicity.
4. A nurse is providing discharge teaching to a mother whose infant was treated with phototherapy for
hyperbilirubinemia. Which statement by the mother indicates a need for further teaching?
A. I will continue to breastfeed my baby every 2 to 3 hours.
, B. I will keep my baby’s skin well-hydrated by applying lotion.
C. I will monitor the number of wet and dirty diapers my baby has.
D. I will check my baby’s skin color in natural light.
Correct Answer: B
Rationale: Lotion or oils should never be applied to a baby’s skin during phototherapy because they can
cause burns under the lights. Maintaining hydration through frequent breastfeeding is critical to help the
baby excrete bilirubin through stools and urine. The mother should monitor diaper counts to ensure the
infant is receiving adequate fluids. Checking the skin in natural light provides the most accurate
assessment of jaundice levels. Teaching these safety measures helps prevent skin damage and ensures
effective treatment of hyperbilirubinemia.
5. A 2-year-old child is brought to the emergency department with suspected epiglottitis. Which action
should the nurse avoid performing?
A. Attempting to visualize the throat with a tongue depressor.
B. Providing humidified oxygen via a mask.
C. Encouraging the child to sit in a tripod position.
D. Keeping the child as calm and quiet as possible.
Correct Answer: A
Rationale: Using a tongue depressor or any instrument in the throat of a child with suspected epiglottitis
can trigger a fatal laryngospasm. The nurse must avoid invasive assessments until an artificial airway can
be established by an expert team. Epiglottitis is a medical emergency characterized by a high fever,
drooling, and respiratory distress. Sitting in a tripod position helps the child maintain a patent airway by
