NUR 230: Maternal & Pediatric Nursing Final Exam 2026 |Galen
College
1. A nurse is assessing a client who is at 34 weeks of gestation and has mild
preeclampsia. Which of the following findings should the nurse report to the
provider?
A. 1+ edema of the ankles
B. Urine output of 40 mL/hr
C. Platelet count of 70,000/mm3
D. Blood pressure 142/92 mm Hg
Answer: C
Rationale: A platelet count of 70,000/mm3 is significantly below the normal range
(150,000-400,000) and indicates thrombocytopenia, which is a sign of worsening
preeclampsia or HELLP syndrome.
2. A nurse is caring for a client who is in the first stage of labor and has an
umbilical cord prolapse. Which of the following actions should the nurse take
first?
A. Monitor the fetal heart rate
B. Notify the provider
C. Place the client in a knee-chest position
D. Prepare the client for a cesarean birth
Answer: C
Rationale: The priority action is to relieve pressure on the umbilical cord to maintain fetal
oxygenation. Placing the client in a knee-chest or Trendelenburg position uses gravity to
shift the fetus off the cord.
,3. A nurse is caring for a newborn immediately after birth. Which of the
following is the priority nursing action?
A. Administer Vitamin K intramuscularly
B. Place the newborn skin-to-skin with the mother
C. Apply erythromycin ophthalmic ointment
D. Dry the newborn thoroughly
Answer: D
Rationale: Drying the newborn is the priority action to prevent heat loss through
evaporation and to provide tactile stimulation to initiate breathing.
4. A nurse is assessing a 6-month-old infant during a well-child visit. Which of
the following motor skills should the nurse expect the infant to demonstrate?
A. Walking while holding onto furniture
B. Turning from back to stomach
C. Sitting steadily without support
D. Using a neat pincer grasp
Answer: B
Rationale: By 6 months of age, an infant should be able to roll from their back to their
stomach. Sitting without support usually occurs by 8 months, and walking/pincer grasp
occur later.
5. A nurse is teaching a client who is at 12 weeks of gestation about nutrition.
Which of the following statements by the client indicates an understanding of
the teaching?
A. I should increase my caloric intake by 500 calories per day now.
B. I will double my intake of Vitamin A to prevent birth defects.
C. I should take my iron supplement with a glass of orange juice.
D. I will limit my protein intake to 40 grams per day.
Answer: C
, Rationale: Vitamin C, found in orange juice, increases the absorption of iron. Caloric
increases are generally not recommended until the second trimester (340 kcal).
6. A nurse is monitoring a client who is receiving magnesium sulfate for
preeclampsia. Which of the following findings is a sign of magnesium toxicity?
A. Respiratory rate of 10/min
B. Deep tendon reflexes 2+
C. Urine output of 50 mL/hr
D. Presence of a fetal heart rate baseline of 140/min
Answer: A
Rationale: Signs of magnesium toxicity include respiratory depression (less than 12/min),
loss of deep tendon reflexes, and decreased urinary output. 10/min is too low.
7. A nurse is caring for a child who has cystic fibrosis. Which of the following
interventions should the nurse include in the plan of care?
A. Administer pancreatic enzymes 2 hours after meals
B. Limit physical activity to prevent fatigue
C. Perform chest physiotherapy twice daily
D. Provide a low-protein, low-calorie diet
Answer: C
Rationale: Chest physiotherapy is essential for clearing thick secretions from the airways
in patients with cystic fibrosis. Enzymes should be given with meals, and a high-calorie diet
is needed.
College
1. A nurse is assessing a client who is at 34 weeks of gestation and has mild
preeclampsia. Which of the following findings should the nurse report to the
provider?
A. 1+ edema of the ankles
B. Urine output of 40 mL/hr
C. Platelet count of 70,000/mm3
D. Blood pressure 142/92 mm Hg
Answer: C
Rationale: A platelet count of 70,000/mm3 is significantly below the normal range
(150,000-400,000) and indicates thrombocytopenia, which is a sign of worsening
preeclampsia or HELLP syndrome.
2. A nurse is caring for a client who is in the first stage of labor and has an
umbilical cord prolapse. Which of the following actions should the nurse take
first?
A. Monitor the fetal heart rate
B. Notify the provider
C. Place the client in a knee-chest position
D. Prepare the client for a cesarean birth
Answer: C
Rationale: The priority action is to relieve pressure on the umbilical cord to maintain fetal
oxygenation. Placing the client in a knee-chest or Trendelenburg position uses gravity to
shift the fetus off the cord.
,3. A nurse is caring for a newborn immediately after birth. Which of the
following is the priority nursing action?
A. Administer Vitamin K intramuscularly
B. Place the newborn skin-to-skin with the mother
C. Apply erythromycin ophthalmic ointment
D. Dry the newborn thoroughly
Answer: D
Rationale: Drying the newborn is the priority action to prevent heat loss through
evaporation and to provide tactile stimulation to initiate breathing.
4. A nurse is assessing a 6-month-old infant during a well-child visit. Which of
the following motor skills should the nurse expect the infant to demonstrate?
A. Walking while holding onto furniture
B. Turning from back to stomach
C. Sitting steadily without support
D. Using a neat pincer grasp
Answer: B
Rationale: By 6 months of age, an infant should be able to roll from their back to their
stomach. Sitting without support usually occurs by 8 months, and walking/pincer grasp
occur later.
5. A nurse is teaching a client who is at 12 weeks of gestation about nutrition.
Which of the following statements by the client indicates an understanding of
the teaching?
A. I should increase my caloric intake by 500 calories per day now.
B. I will double my intake of Vitamin A to prevent birth defects.
C. I should take my iron supplement with a glass of orange juice.
D. I will limit my protein intake to 40 grams per day.
Answer: C
, Rationale: Vitamin C, found in orange juice, increases the absorption of iron. Caloric
increases are generally not recommended until the second trimester (340 kcal).
6. A nurse is monitoring a client who is receiving magnesium sulfate for
preeclampsia. Which of the following findings is a sign of magnesium toxicity?
A. Respiratory rate of 10/min
B. Deep tendon reflexes 2+
C. Urine output of 50 mL/hr
D. Presence of a fetal heart rate baseline of 140/min
Answer: A
Rationale: Signs of magnesium toxicity include respiratory depression (less than 12/min),
loss of deep tendon reflexes, and decreased urinary output. 10/min is too low.
7. A nurse is caring for a child who has cystic fibrosis. Which of the following
interventions should the nurse include in the plan of care?
A. Administer pancreatic enzymes 2 hours after meals
B. Limit physical activity to prevent fatigue
C. Perform chest physiotherapy twice daily
D. Provide a low-protein, low-calorie diet
Answer: C
Rationale: Chest physiotherapy is essential for clearing thick secretions from the airways
in patients with cystic fibrosis. Enzymes should be given with meals, and a high-calorie diet
is needed.
