NUR166/NUR 166 Final Exam V3 |
Concepts of Family Centered Nursing for
the Practical Nurse Q&A with Rationale |
Hondros College of Nursing
1. A pregnant client at 32 weeks gestation reports sudden, painless bright red vaginal
bleeding. Which condition should the practical nurse suspect?
A. Abruptio Placentae
B. Spontaneous Abortion
C. Ectopic Pregnancy
D. Placenta Previa
Correct Answer: D
Rationale: Placenta previa is characterized by painless, bright red vaginal bleeding in the
third trimester as the placenta covers the cervical os. In contrast, abruptio placentae
typically involves painful bleeding and a rigid abdomen. The practical nurse must avoid
vaginal exams in these clients to prevent further hemorrhage.
2. Which assessment finding in a client receiving magnesium sulfate for preeclampsia
indicates potential toxicity?
A. Blood pressure of 140/90 mmHg
B. Respiratory rate of 10 breaths per minute
,C. Hyperactive deep tendon reflexes (4+)
D. Increased urinary output
Correct Answer: B
Rationale: Magnesium sulfate toxicity is marked by respiratory depression, loss of deep
tendon reflexes, and decreased urine output. A respiratory rate of 10 is below the normal
threshold and requires immediate intervention. The nurse should have calcium gluconate
available as the antidote.
3. A newborn has an APGAR score of 9 at 1 minute. Which of the following best describes this
finding?
A. The infant requires immediate resuscitation.
B. The infant is in severe distress.
C. The infant is showing good adjustment to extrauterine life.
D. The infant has moderate difficulty breathing.
Correct Answer: C
Rationale: APGAR scores between 7 and 10 indicate that the newborn is in good condition
and adjusting well. The score is calculated based on heart rate, respiratory effort, muscle
tone, reflex irritability, and color. A score of 9 usually means only one point was deducted,
often for acrocyanosis.
, 4. A postpartum nurse is assessing a client 2 hours after delivery. The fundus is boggy and
displaced to the right. What is the priority nursing action?
A. Assist the client to the bathroom to void.
B. Notify the healthcare provider immediately.
C. Massage the fundus until firm.
D. Administer oxytocin as ordered.
Correct Answer: A
Rationale: A displaced fundus to the right or left usually indicates a distended bladder,
which prevents the uterus from contracting. Assisting the client to void will allow the
uterus to return to the midline and firm up. If the fundus remains boggy after voiding,
fundal massage would be the next step.
5. Which developmental milestone should the nurse expect a 6-month-old infant to have
achieved?
A. Walking while holding onto furniture
B. Sitting steadily without support
C. Rolling from back to abdomen
D. Using a pincer grasp
Correct Answer: C
Concepts of Family Centered Nursing for
the Practical Nurse Q&A with Rationale |
Hondros College of Nursing
1. A pregnant client at 32 weeks gestation reports sudden, painless bright red vaginal
bleeding. Which condition should the practical nurse suspect?
A. Abruptio Placentae
B. Spontaneous Abortion
C. Ectopic Pregnancy
D. Placenta Previa
Correct Answer: D
Rationale: Placenta previa is characterized by painless, bright red vaginal bleeding in the
third trimester as the placenta covers the cervical os. In contrast, abruptio placentae
typically involves painful bleeding and a rigid abdomen. The practical nurse must avoid
vaginal exams in these clients to prevent further hemorrhage.
2. Which assessment finding in a client receiving magnesium sulfate for preeclampsia
indicates potential toxicity?
A. Blood pressure of 140/90 mmHg
B. Respiratory rate of 10 breaths per minute
,C. Hyperactive deep tendon reflexes (4+)
D. Increased urinary output
Correct Answer: B
Rationale: Magnesium sulfate toxicity is marked by respiratory depression, loss of deep
tendon reflexes, and decreased urine output. A respiratory rate of 10 is below the normal
threshold and requires immediate intervention. The nurse should have calcium gluconate
available as the antidote.
3. A newborn has an APGAR score of 9 at 1 minute. Which of the following best describes this
finding?
A. The infant requires immediate resuscitation.
B. The infant is in severe distress.
C. The infant is showing good adjustment to extrauterine life.
D. The infant has moderate difficulty breathing.
Correct Answer: C
Rationale: APGAR scores between 7 and 10 indicate that the newborn is in good condition
and adjusting well. The score is calculated based on heart rate, respiratory effort, muscle
tone, reflex irritability, and color. A score of 9 usually means only one point was deducted,
often for acrocyanosis.
, 4. A postpartum nurse is assessing a client 2 hours after delivery. The fundus is boggy and
displaced to the right. What is the priority nursing action?
A. Assist the client to the bathroom to void.
B. Notify the healthcare provider immediately.
C. Massage the fundus until firm.
D. Administer oxytocin as ordered.
Correct Answer: A
Rationale: A displaced fundus to the right or left usually indicates a distended bladder,
which prevents the uterus from contracting. Assisting the client to void will allow the
uterus to return to the midline and firm up. If the fundus remains boggy after voiding,
fundal massage would be the next step.
5. Which developmental milestone should the nurse expect a 6-month-old infant to have
achieved?
A. Walking while holding onto furniture
B. Sitting steadily without support
C. Rolling from back to abdomen
D. Using a pincer grasp
Correct Answer: C
