NUR 230 Maternal & Pediatric Nursing Exam 5 2026 |Galen College
1. A nurse is assessing a postpartum client who is 4 hours post-delivery. The
nurse notes the fundus is firm, midline, but the client is experiencing heavy
vaginal bleeding with large clots. What is the priority nursing action?
A. Perform fundal massage immediately
B. Check for a full bladder
C. Notify the provider of the findings
D. Administer oxytocin as ordered
Answer: C
Rationale: Since the fundus is already firm and midline, fundal massage or checking for a
full bladder (which would displace the fundus) are not the priorities. Heavy bleeding with a
firm fundus may indicate a laceration that needs medical intervention.
2. Which assessment finding in a 2-hour-old newborn should the nurse report to
the pediatrician immediately?
A. Acrocyanosis in the hands and feet
B. Heart rate of 140 beats per minute
C. Nasal flaring and chest retractions
D. Blood glucose of 50 mg/dL
Answer: C
Rationale: Nasal flaring and chest retractions are signs of respiratory distress syndrome
and require immediate intervention. Acrocyanosis is normal in the first 24 hours, and the
heart rate and glucose are within normal ranges.
,3. A mother of a 4-year-old child expresses concern that her child is ‘imagining
things’ and talks to an invisible friend. What is the nurse’s best response?
A. We need to refer your child for a psychological evaluation.
B. Your child may be experiencing social anxiety.
C. You should discourage this behavior to avoid confusion.
D. This is a normal part of preschool development.
Answer: D
Rationale: Preschool-age children (3-6 years) commonly have imaginary friends as part of
their cognitive development and Piaget’s preoperational stage.
4. A child with cystic fibrosis is being discharged. Which dietary instruction
should the nurse include?
A. Administer pancreatic enzymes with all meals and snacks.
B. Restrict fat intake to prevent steatorrhea.
C. Maintain a low-calorie, low-protein diet.
D. Limit salt intake during the summer months.
Answer: A
Rationale: Children with cystic fibrosis require pancreatic enzymes with every meal and
snack to facilitate the absorption of fats, proteins, and carbohydrates due to pancreatic
insufficiency.
5. A nurse is caring for a 6-month-old infant admitted with RSV (Respiratory
Syncytial Virus). What type of precautions should be implemented?
A. Contact and Droplet precautions
B. Airborne precautions
C. Standard precautions only
D. Protective environment precautions
Answer: A
, Rationale: RSV is primarily spread through direct contact with secretions and large-
particle droplets; therefore, contact and droplet precautions are standard protocol.
6. Which finding is considered a classic sign of pyloric stenosis in an infant?
A. Projectile vomiting after feedings
B. Currant jelly-like stools
C. Abdominal distention and bile-stained emesis
D. Failure to pass meconium within 24 hours
Answer: A
Rationale: Projectile, non-bilious vomiting after feedings is the hallmark sign of pyloric
stenosis. Currant jelly stools are associated with intussusception.
7. When performing a physical assessment on a 2-year-old child, in what order
should the nurse perform the tasks?
A. Head to toe, starting with the ears and throat
B. Least invasive to most invasive
C. Most invasive to least invasive
D. Whatever order the parent suggests
Answer: B
Rationale: For toddlers, it is best to perform non-invasive tasks first (like auscultation) to
build trust and keep the child calm before performing distressing tasks like checking ears
or throat.
8. A child is admitted with suspected acute epiglottitis. Which action should the
nurse avoid?
A. Providing humidified oxygen
B. Placing the child in an upright position
C. Keeping an intubation tray at the bedside
D. Using a tongue blade to visualize the throat
Answer: D
1. A nurse is assessing a postpartum client who is 4 hours post-delivery. The
nurse notes the fundus is firm, midline, but the client is experiencing heavy
vaginal bleeding with large clots. What is the priority nursing action?
A. Perform fundal massage immediately
B. Check for a full bladder
C. Notify the provider of the findings
D. Administer oxytocin as ordered
Answer: C
Rationale: Since the fundus is already firm and midline, fundal massage or checking for a
full bladder (which would displace the fundus) are not the priorities. Heavy bleeding with a
firm fundus may indicate a laceration that needs medical intervention.
2. Which assessment finding in a 2-hour-old newborn should the nurse report to
the pediatrician immediately?
A. Acrocyanosis in the hands and feet
B. Heart rate of 140 beats per minute
C. Nasal flaring and chest retractions
D. Blood glucose of 50 mg/dL
Answer: C
Rationale: Nasal flaring and chest retractions are signs of respiratory distress syndrome
and require immediate intervention. Acrocyanosis is normal in the first 24 hours, and the
heart rate and glucose are within normal ranges.
,3. A mother of a 4-year-old child expresses concern that her child is ‘imagining
things’ and talks to an invisible friend. What is the nurse’s best response?
A. We need to refer your child for a psychological evaluation.
B. Your child may be experiencing social anxiety.
C. You should discourage this behavior to avoid confusion.
D. This is a normal part of preschool development.
Answer: D
Rationale: Preschool-age children (3-6 years) commonly have imaginary friends as part of
their cognitive development and Piaget’s preoperational stage.
4. A child with cystic fibrosis is being discharged. Which dietary instruction
should the nurse include?
A. Administer pancreatic enzymes with all meals and snacks.
B. Restrict fat intake to prevent steatorrhea.
C. Maintain a low-calorie, low-protein diet.
D. Limit salt intake during the summer months.
Answer: A
Rationale: Children with cystic fibrosis require pancreatic enzymes with every meal and
snack to facilitate the absorption of fats, proteins, and carbohydrates due to pancreatic
insufficiency.
5. A nurse is caring for a 6-month-old infant admitted with RSV (Respiratory
Syncytial Virus). What type of precautions should be implemented?
A. Contact and Droplet precautions
B. Airborne precautions
C. Standard precautions only
D. Protective environment precautions
Answer: A
, Rationale: RSV is primarily spread through direct contact with secretions and large-
particle droplets; therefore, contact and droplet precautions are standard protocol.
6. Which finding is considered a classic sign of pyloric stenosis in an infant?
A. Projectile vomiting after feedings
B. Currant jelly-like stools
C. Abdominal distention and bile-stained emesis
D. Failure to pass meconium within 24 hours
Answer: A
Rationale: Projectile, non-bilious vomiting after feedings is the hallmark sign of pyloric
stenosis. Currant jelly stools are associated with intussusception.
7. When performing a physical assessment on a 2-year-old child, in what order
should the nurse perform the tasks?
A. Head to toe, starting with the ears and throat
B. Least invasive to most invasive
C. Most invasive to least invasive
D. Whatever order the parent suggests
Answer: B
Rationale: For toddlers, it is best to perform non-invasive tasks first (like auscultation) to
build trust and keep the child calm before performing distressing tasks like checking ears
or throat.
8. A child is admitted with suspected acute epiglottitis. Which action should the
nurse avoid?
A. Providing humidified oxygen
B. Placing the child in an upright position
C. Keeping an intubation tray at the bedside
D. Using a tongue blade to visualize the throat
Answer: D
