NUR254 Concepts of Nursing; The Childbearing
and Child Caring Families Exam 2 Version 2
Questions with Correct Answers and Expert
Explanation for Each Question | Galen
1. A nurse is caring for a client at 36 weeks gestation who presents with painless,
bright red vaginal bleeding. What is the priority nursing action?
A. Perform a sterile vaginal exam to check for dilation.
B. Prepare the client for an immediate vaginal delivery.
C. Initiate continuous external fetal monitoring.
D. Apply a fundal pressure to stop the bleeding.
Correct Answer: C
Expert Explanation: Painless bright red bleeding is a classic sign of placenta previa.
A vaginal examination is strictly contraindicated because it may cause massive
hemorrhage. The nurse must prioritize monitoring the fetal heart rate to ensure
fetal well-being during the bleeding episode. Preparing for a vaginal delivery is
incorrect as a cesarean section is usually required for complete previa. Continuous
assessment of maternal vital signs and blood loss is also essential for safety.
,2. A laboring client’s fetal heart rate monitor shows late decelerations. Which
intervention should the nurse perform first?
A. Increase the rate of the oxytocin infusion.
B. Reposition the client to a side-lying position.
C. Administer oxygen via nasal cannula at 2L/min.
D. Document the findings as a normal variation.
Correct Answer: B
Expert Explanation: Late decelerations are indicative of uteroplacental
insufficiency and require immediate intervention. The first step is to reposition the
mother to the left or right side to improve blood flow to the placenta. Oxytocin
should be discontinued immediately rather than increased if it is being infused.
Oxygen should be administered via a non-rebreather mask at 8-10L/min for better
oxygenation. These actions are prioritized to restore fetal oxygenation and prevent
hypoxia.
3. Which assessment finding in a client receiving magnesium sulfate for preeclampsia
indicates toxicity?
A. Respiratory rate of 10 breaths per minute.
B. Urine output of 50 mL/hour.
C. Deep tendon reflexes of 2+.
,D. Maternal heart rate of 90 beats per minute.
Correct Answer: A
Expert Explanation: Magnesium sulfate is a central nervous system depressant
used to prevent seizures. A respiratory rate below 12 breaths per minute is a
primary indicator of magnesium toxicity. Other signs include absent deep tendon
reflexes and a significant drop in urine output. The nurse must monitor these
parameters closely every hour during the infusion. If toxicity is suspected, the
infusion should be stopped and calcium gluconate should be administered.
4. A 4-year-old child is admitted with suspected epiglottitis. Which action by the nurse
is the most appropriate?
A. Obtain a throat culture to identify the causative organism.
B. Keep the child in an upright position and minimize stress.
C. Encourage the child to lie flat to ease breathing.
D. Examine the throat using a tongue blade.
Correct Answer: B
Expert Explanation: Epiglottitis is a medical emergency that can lead to sudden
airway obstruction. Inserting anything into the throat, such as a tongue blade or
culture swab, can trigger laryngospasm. The child should be allowed to remain in a
position of comfort, usually sitting upright in a ‘tripod’ position. Minimizing stress is
, crucial to prevent the child from crying and further compromising the airway.
Emergency intubation equipment must be kept at the bedside at all times.
5. A nurse is assessing a newborn 1 minute after birth. The heart rate is 110 bpm,
there is a weak cry, some flexion of extremities, the body is pink with blue
extremities, and the baby grimaces when stimulated. What is the Apgar score?
A. 6
B. 5
C. 7
D. 8
Correct Answer: A
Expert Explanation: The Apgar score is calculated by evaluating five categories:
heart rate, respiratory effort, muscle tone, reflex irritability, and color. This newborn
receives 2 points for heart rate, 1 for a weak cry, 1 for flexion, 1 for grimace, and 1
for acrocyanosis. Summing these values results in a total Apgar score of 6. A score of
4 to 6 indicates moderate distress requiring some resuscitation measures. The score
is typically assessed at 1 minute and 5 minutes after birth.
6. During the active phase of the first stage of labor, a client’s membranes rupture.
What is the nurse’s priority assessment?
A. Assess the color and odor of the amniotic fluid.
and Child Caring Families Exam 2 Version 2
Questions with Correct Answers and Expert
Explanation for Each Question | Galen
1. A nurse is caring for a client at 36 weeks gestation who presents with painless,
bright red vaginal bleeding. What is the priority nursing action?
A. Perform a sterile vaginal exam to check for dilation.
B. Prepare the client for an immediate vaginal delivery.
C. Initiate continuous external fetal monitoring.
D. Apply a fundal pressure to stop the bleeding.
Correct Answer: C
Expert Explanation: Painless bright red bleeding is a classic sign of placenta previa.
A vaginal examination is strictly contraindicated because it may cause massive
hemorrhage. The nurse must prioritize monitoring the fetal heart rate to ensure
fetal well-being during the bleeding episode. Preparing for a vaginal delivery is
incorrect as a cesarean section is usually required for complete previa. Continuous
assessment of maternal vital signs and blood loss is also essential for safety.
,2. A laboring client’s fetal heart rate monitor shows late decelerations. Which
intervention should the nurse perform first?
A. Increase the rate of the oxytocin infusion.
B. Reposition the client to a side-lying position.
C. Administer oxygen via nasal cannula at 2L/min.
D. Document the findings as a normal variation.
Correct Answer: B
Expert Explanation: Late decelerations are indicative of uteroplacental
insufficiency and require immediate intervention. The first step is to reposition the
mother to the left or right side to improve blood flow to the placenta. Oxytocin
should be discontinued immediately rather than increased if it is being infused.
Oxygen should be administered via a non-rebreather mask at 8-10L/min for better
oxygenation. These actions are prioritized to restore fetal oxygenation and prevent
hypoxia.
3. Which assessment finding in a client receiving magnesium sulfate for preeclampsia
indicates toxicity?
A. Respiratory rate of 10 breaths per minute.
B. Urine output of 50 mL/hour.
C. Deep tendon reflexes of 2+.
,D. Maternal heart rate of 90 beats per minute.
Correct Answer: A
Expert Explanation: Magnesium sulfate is a central nervous system depressant
used to prevent seizures. A respiratory rate below 12 breaths per minute is a
primary indicator of magnesium toxicity. Other signs include absent deep tendon
reflexes and a significant drop in urine output. The nurse must monitor these
parameters closely every hour during the infusion. If toxicity is suspected, the
infusion should be stopped and calcium gluconate should be administered.
4. A 4-year-old child is admitted with suspected epiglottitis. Which action by the nurse
is the most appropriate?
A. Obtain a throat culture to identify the causative organism.
B. Keep the child in an upright position and minimize stress.
C. Encourage the child to lie flat to ease breathing.
D. Examine the throat using a tongue blade.
Correct Answer: B
Expert Explanation: Epiglottitis is a medical emergency that can lead to sudden
airway obstruction. Inserting anything into the throat, such as a tongue blade or
culture swab, can trigger laryngospasm. The child should be allowed to remain in a
position of comfort, usually sitting upright in a ‘tripod’ position. Minimizing stress is
, crucial to prevent the child from crying and further compromising the airway.
Emergency intubation equipment must be kept at the bedside at all times.
5. A nurse is assessing a newborn 1 minute after birth. The heart rate is 110 bpm,
there is a weak cry, some flexion of extremities, the body is pink with blue
extremities, and the baby grimaces when stimulated. What is the Apgar score?
A. 6
B. 5
C. 7
D. 8
Correct Answer: A
Expert Explanation: The Apgar score is calculated by evaluating five categories:
heart rate, respiratory effort, muscle tone, reflex irritability, and color. This newborn
receives 2 points for heart rate, 1 for a weak cry, 1 for flexion, 1 for grimace, and 1
for acrocyanosis. Summing these values results in a total Apgar score of 6. A score of
4 to 6 indicates moderate distress requiring some resuscitation measures. The score
is typically assessed at 1 minute and 5 minutes after birth.
6. During the active phase of the first stage of labor, a client’s membranes rupture.
What is the nurse’s priority assessment?
A. Assess the color and odor of the amniotic fluid.
