NUR254 | NUR254 Concepts of Nursing; The
Childbearing and Child Caring Families Exam 4
Version 3 Questions with Correct Answers and
Expert Explanation for Each Question | Galen
1. A nurse is assessing a postpartum client 2 hours after delivery and notes the fundus
is boggy and displaced to the right. Which action should the nurse take first?
A. Assist the client to the bathroom to void.
B. Massage the fundus until firm.
C. Administer oxytocin as prescribed.
D. Notify the healthcare provider immediately.
Correct Answer: A
Expert Explanation: A displaced fundus usually indicates a distended bladder that
is preventing the uterus from contracting effectively. Assisting the client to void is
the priority intervention to allow the uterus to return to the midline. Once the
bladder is empty, the nurse can reassess the firmness of the fundus. Massaging a
boggy fundus is important, but the cause of displacement must be addressed first.
This clinical reasoning ensures patient safety and prevents further postpartum
hemorrhage.
,2. A newborn is undergoing phototherapy for hyperbilirubinemia. Which nursing
intervention is essential for safety and outcome monitoring?
A. Apply lotion to the skin to prevent dryness.
B. Limit fluid intake to concentrate the urine.
C. Cover the newborn’s eyes with opaque masks.
D. Keep the newborn in a prone position exclusively.
Correct Answer: C
Expert Explanation: Protecting the newborn’s eyes with opaque masks is a critical
safety measure to prevent retinal damage from the high-intensity light. The nurse
must also monitor the infant’s temperature frequently to prevent overheating.
Hydration should be maintained or increased to facilitate the excretion of bilirubin
through stool and urine. Lotions should be avoided as they can cause skin burns
under the phototherapy lights. This comprehensive care approach ensures effective
treatment while minimizing potential complications.
3. A 4-year-old child is admitted with a diagnosis of acute epiglottitis. Which action by
the nurse is contraindicated?
A. Encouraging a sitting position.
B. Keeping the child as calm as possible.
C. Administering humidified oxygen.
,D. Using a tongue depressor to visualize the throat.
Correct Answer: D
Expert Explanation: Inserting a tongue depressor or any object into the throat of a
child with suspected epiglottitis can trigger a complete airway obstruction. The
nurse should maintain the child in a comfortable, upright position to ease breathing.
It is vital to have emergency intubation equipment ready at the bedside. Calmness is
prioritized because agitation can worsen respiratory distress and airway swelling.
This intervention reflects critical safety protocols for pediatric respiratory
emergencies.
4. Which clinical finding in a 6-month-old infant is a significant indicator of severe
dehydration?
A. Brisk capillary refill of less than 2 seconds.
B. Sunken anterior fontanel.
C. Moist mucous membranes.
D. Normal skin turgor.
Correct Answer: B
Expert Explanation: A sunken anterior fontanel is a classic sign of significant fluid
volume deficit in an infant. Other signs include decreased tear production, dry
mucous membranes, and poor skin turgor. The nurse must assess the infant’s
, weight and urine output to determine the severity of dehydration. Brisk capillary
refill and moist membranes are signs of adequate hydration. Timely identification of
these symptoms allows for rapid intervention with oral or intravenous fluids.
5. A nurse is teaching the mother of an infant with Neonatal Abstinence Syndrome
(NAS). Which instruction should be included?
A. Provide frequent, high-stimulation environments.
B. Use swaddling and rhythmic swaying to soothe.
C. Wake the baby every hour for assessment.
D. Discourage breastfeeding in all cases.
Correct Answer: B
Expert Explanation: Infants with Neonatal Abstinence Syndrome (NAS) benefit
from a low-stimulation environment to manage irritability and tremors. Swaddling
provides comfort and helps reduce the self-disturbing movements common in drug
withdrawal. The nurse should encourage small, frequent feedings to address high
caloric needs and potential vomiting. Rhythmic swaying and vertical rocking are
effective non-pharmacological soothing techniques. Education focuses on patient-
centered care to help the mother bond while managing the infant’s symptoms.
Childbearing and Child Caring Families Exam 4
Version 3 Questions with Correct Answers and
Expert Explanation for Each Question | Galen
1. A nurse is assessing a postpartum client 2 hours after delivery and notes the fundus
is boggy and displaced to the right. Which action should the nurse take first?
A. Assist the client to the bathroom to void.
B. Massage the fundus until firm.
C. Administer oxytocin as prescribed.
D. Notify the healthcare provider immediately.
Correct Answer: A
Expert Explanation: A displaced fundus usually indicates a distended bladder that
is preventing the uterus from contracting effectively. Assisting the client to void is
the priority intervention to allow the uterus to return to the midline. Once the
bladder is empty, the nurse can reassess the firmness of the fundus. Massaging a
boggy fundus is important, but the cause of displacement must be addressed first.
This clinical reasoning ensures patient safety and prevents further postpartum
hemorrhage.
,2. A newborn is undergoing phototherapy for hyperbilirubinemia. Which nursing
intervention is essential for safety and outcome monitoring?
A. Apply lotion to the skin to prevent dryness.
B. Limit fluid intake to concentrate the urine.
C. Cover the newborn’s eyes with opaque masks.
D. Keep the newborn in a prone position exclusively.
Correct Answer: C
Expert Explanation: Protecting the newborn’s eyes with opaque masks is a critical
safety measure to prevent retinal damage from the high-intensity light. The nurse
must also monitor the infant’s temperature frequently to prevent overheating.
Hydration should be maintained or increased to facilitate the excretion of bilirubin
through stool and urine. Lotions should be avoided as they can cause skin burns
under the phototherapy lights. This comprehensive care approach ensures effective
treatment while minimizing potential complications.
3. A 4-year-old child is admitted with a diagnosis of acute epiglottitis. Which action by
the nurse is contraindicated?
A. Encouraging a sitting position.
B. Keeping the child as calm as possible.
C. Administering humidified oxygen.
,D. Using a tongue depressor to visualize the throat.
Correct Answer: D
Expert Explanation: Inserting a tongue depressor or any object into the throat of a
child with suspected epiglottitis can trigger a complete airway obstruction. The
nurse should maintain the child in a comfortable, upright position to ease breathing.
It is vital to have emergency intubation equipment ready at the bedside. Calmness is
prioritized because agitation can worsen respiratory distress and airway swelling.
This intervention reflects critical safety protocols for pediatric respiratory
emergencies.
4. Which clinical finding in a 6-month-old infant is a significant indicator of severe
dehydration?
A. Brisk capillary refill of less than 2 seconds.
B. Sunken anterior fontanel.
C. Moist mucous membranes.
D. Normal skin turgor.
Correct Answer: B
Expert Explanation: A sunken anterior fontanel is a classic sign of significant fluid
volume deficit in an infant. Other signs include decreased tear production, dry
mucous membranes, and poor skin turgor. The nurse must assess the infant’s
, weight and urine output to determine the severity of dehydration. Brisk capillary
refill and moist membranes are signs of adequate hydration. Timely identification of
these symptoms allows for rapid intervention with oral or intravenous fluids.
5. A nurse is teaching the mother of an infant with Neonatal Abstinence Syndrome
(NAS). Which instruction should be included?
A. Provide frequent, high-stimulation environments.
B. Use swaddling and rhythmic swaying to soothe.
C. Wake the baby every hour for assessment.
D. Discourage breastfeeding in all cases.
Correct Answer: B
Expert Explanation: Infants with Neonatal Abstinence Syndrome (NAS) benefit
from a low-stimulation environment to manage irritability and tremors. Swaddling
provides comfort and helps reduce the self-disturbing movements common in drug
withdrawal. The nurse should encourage small, frequent feedings to address high
caloric needs and potential vomiting. Rhythmic swaying and vertical rocking are
effective non-pharmacological soothing techniques. Education focuses on patient-
centered care to help the mother bond while managing the infant’s symptoms.
