NUR166/NUR 166 Exam 3 V1 | Concepts of
Family Centered Nursing for the Practical
Nurse Q&A with Rationale | Hondros
College of Nursing
1. A nurse is assessing a postpartum client 4 hours after delivery and finds the fundus is boggy
and displaced to the right. Which action should the nurse take first?
A. Administer oxytocin as ordered
B. Notify the provider immediately
C. Perform a fundal massage
D. Encourage the client to void
Correct Answer: D
Rationale: A fundus that is displaced to the right usually indicates a full bladder which
prevents the uterus from contracting. Encouraging the client to void or catheterizing if
necessary is the priority to allow the uterus to return to the midline. Once the bladder is
empty, the nurse can reassess fundal firmness and position.
2. An infant’s APGAR score at 1 minute is 8 and at 5 minutes is 9. How should the nurse
interpret these findings?
A. The infant requires immediate resuscitation
B. The infant is experiencing moderate respiratory distress
,C. The infant is adjusting well to extrauterine life
D. The infant needs to be placed in a neonatal intensive care unit
Correct Answer: C
Rationale: An APGAR score between 7 and 10 indicates that the newborn is in good
condition and adjusting well. These scores reflect heart rate, respiratory effort, muscle
tone, reflex irritability, and color. Continuous monitoring is standard care for infants with
these healthy scores.
3. A nurse is providing teaching to the mother of a newborn with hyperbilirubinemia who is
receiving phototherapy. Which statement by the mother indicates understanding?
A. I should apply lotion to my baby’s skin to prevent drying.
B. I will keep my baby dressed in a onesie during the treatment.
C. I should limit my baby’s fluid intake to prevent diarrhea.
D. I will keep my baby’s eyes covered with the patches while under the lights.
Correct Answer: D
Rationale: Eye patches are essential during phototherapy to protect the newborn’s retina
from the high-intensity lights. The baby should be undressed except for a diaper to
maximize skin exposure to the light. Lotions should be avoided as they can cause burns
under the phototherapy unit.
, 4. According to Erikson, a 9-year-old child is in which stage of psychosocial development?
A. Industry vs. Inferiority
B. Initiative vs. Guilt
C. Autonomy vs. Shame and Doubt
D. Identity vs. Role Confusion
Correct Answer: A
Rationale: School-aged children (6 to 12 years) are in the Industry vs. Inferiority stage.
During this time, they focus on mastering skills and completing tasks to develop a sense of
competence. Failure to achieve these milestones can lead to feelings of inadequacy or
inferiority.
5. A nurse is assessing a toddler during a well-child visit. Which developmental milestone is
expected for a 2-year-old?
A. Using a fork to eat independently
B. Walking up and down stairs alone
C. Tying shoelaces
D. Speaking in 2- to 3-word phrases
Correct Answer: D
Rationale: By age 2, toddlers are typically expected to use short phrases and have a
vocabulary of about 50 to 200 words. Walking up stairs usually involves holding onto a rail
Family Centered Nursing for the Practical
Nurse Q&A with Rationale | Hondros
College of Nursing
1. A nurse is assessing a postpartum client 4 hours after delivery and finds the fundus is boggy
and displaced to the right. Which action should the nurse take first?
A. Administer oxytocin as ordered
B. Notify the provider immediately
C. Perform a fundal massage
D. Encourage the client to void
Correct Answer: D
Rationale: A fundus that is displaced to the right usually indicates a full bladder which
prevents the uterus from contracting. Encouraging the client to void or catheterizing if
necessary is the priority to allow the uterus to return to the midline. Once the bladder is
empty, the nurse can reassess fundal firmness and position.
2. An infant’s APGAR score at 1 minute is 8 and at 5 minutes is 9. How should the nurse
interpret these findings?
A. The infant requires immediate resuscitation
B. The infant is experiencing moderate respiratory distress
,C. The infant is adjusting well to extrauterine life
D. The infant needs to be placed in a neonatal intensive care unit
Correct Answer: C
Rationale: An APGAR score between 7 and 10 indicates that the newborn is in good
condition and adjusting well. These scores reflect heart rate, respiratory effort, muscle
tone, reflex irritability, and color. Continuous monitoring is standard care for infants with
these healthy scores.
3. A nurse is providing teaching to the mother of a newborn with hyperbilirubinemia who is
receiving phototherapy. Which statement by the mother indicates understanding?
A. I should apply lotion to my baby’s skin to prevent drying.
B. I will keep my baby dressed in a onesie during the treatment.
C. I should limit my baby’s fluid intake to prevent diarrhea.
D. I will keep my baby’s eyes covered with the patches while under the lights.
Correct Answer: D
Rationale: Eye patches are essential during phototherapy to protect the newborn’s retina
from the high-intensity lights. The baby should be undressed except for a diaper to
maximize skin exposure to the light. Lotions should be avoided as they can cause burns
under the phototherapy unit.
, 4. According to Erikson, a 9-year-old child is in which stage of psychosocial development?
A. Industry vs. Inferiority
B. Initiative vs. Guilt
C. Autonomy vs. Shame and Doubt
D. Identity vs. Role Confusion
Correct Answer: A
Rationale: School-aged children (6 to 12 years) are in the Industry vs. Inferiority stage.
During this time, they focus on mastering skills and completing tasks to develop a sense of
competence. Failure to achieve these milestones can lead to feelings of inadequacy or
inferiority.
5. A nurse is assessing a toddler during a well-child visit. Which developmental milestone is
expected for a 2-year-old?
A. Using a fork to eat independently
B. Walking up and down stairs alone
C. Tying shoelaces
D. Speaking in 2- to 3-word phrases
Correct Answer: D
Rationale: By age 2, toddlers are typically expected to use short phrases and have a
vocabulary of about 50 to 200 words. Walking up stairs usually involves holding onto a rail
