NUR166/NUR 166 Exam 2 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 2 hours after delivery and notes the fundus is
boggy and shifted to the right of the midline. Which action should the nurse take first?
A. Massage the uterine fundus until firm.
B. Administer an ordered oxytocic medication.
C. Notify the healthcare provider immediately.
D. Assist the client to the bathroom to void.
Correct Answer: D
Rationale: A fundus that is boggy and displaced to the right is a primary indicator of a
distended bladder. A full bladder prevents the uterus from contracting effectively, which
significantly increases the risk of postpartum hemorrhage. Assisting the client to void is the
priority intervention to allow the uterus to return to the midline and contract properly.
2. A newborn has a heart rate of 110 bpm, a weak cry, some flexion of the extremities,
grimaces when stimulated, and a pink body with blue extremities. What is the assigned
APGAR score?
A. 5
,B. 7
C. 6
D. 8
Correct Answer: C
Rationale: The score is calculated as follows: Heart rate >100 (2), weak cry (1), some
flexion (1), grimace (1), and acrocyanosis (1), totaling 6. APGAR scoring is performed at 1
and 5 minutes to assess the newborn’s immediate transition to extrauterine life. A score of
6 indicates moderate difficulty and requires close observation and potential intervention.
3. A client with preeclampsia is receiving an intravenous infusion of magnesium sulfate. The
nurse notes the client’s respiratory rate is 10 breaths/minute and deep tendon reflexes are
absent. Which medication should the nurse prepare?
A. Naloxone
B. Calcium gluconate
C. Protamine sulfate
D. Vitamin K
Correct Answer: B
Rationale: Calcium gluconate is the specific antidote for magnesium sulfate toxicity and
must be readily available at the bedside. The assessment findings of bradypnea and absent
reflexes are classic signs of magnesium overdose that require immediate reversal. The
,nurse must stop the infusion and notify the provider while preparing the antagonist to
prevent respiratory arrest.
4. Which clinical manifestation should a nurse expect to observe in a client diagnosed with
placenta previa?
A. Board-like, rigid abdomen
B. Severe, unrelenting abdominal pain
C. Dark red vaginal bleeding with contractions
D. Painless, bright red vaginal bleeding
Correct Answer: D
Rationale: Placenta previa is characterized by the painless onset of bright red vaginal
bleeding during the second or third trimester. This occurs because the placenta is
implanted over or near the cervical os, leading to bleeding as the cervix begins to dilate. In
contrast, abruptio placentae typically presents with painful bleeding and a rigid abdomen.
5. The nurse is providing teaching to a new mother about breastfeeding. Which statement by
the mother indicates a need for further instruction?
A. I should feed my baby every 2 to 3 hours.
B. I will wake my baby up to feed if it has been 4 hours.
C. I should ensure the baby has a large portion of the areola in their mouth.
D. I will wash my nipples with soap and water before every feed.
, Correct Answer: D
Rationale: Washing nipples with soap can lead to excessive dryness and cracking, which
increases the risk of infection and pain. Mothers are encouraged to use plain water or
expressed breast milk to clean the area instead. Proper latch technique and frequent
feeding intervals are essential components of successful lactation education.
6. A nurse is caring for a newborn immediately following birth. Which of the following is the
priority nursing action?
A. Administering erythromycin ophthalmic ointment.
B. Drying the infant and maintaining thermoregulation.
C. Applying the identification bands to the infant.
D. Administering the Vitamin K injection.
Correct Answer: B
Rationale: According to the ABCs and neonatal resuscitation guidelines, maintaining
airway and warmth are the highest priorities. Newborns are highly susceptible to cold
stress, which can lead to metabolic acidosis and respiratory distress. While identification
and medications are important, they are performed after the infant is stable and warm.
7. A nurse is teaching a parent of a 2-year-old child about safety. Which of the following
should be included in the teaching?
A. The child should be in a forward-facing car seat regardless of weight.
B. Store household cleaners in a low, unlocked cabinet for easy access.
Family Centered Nursing for the Practical
Nurse Q&A with Rationale | Hondros
College of Nursing
1. A nurse is assessing a postpartum client 2 hours after delivery and notes the fundus is
boggy and shifted to the right of the midline. Which action should the nurse take first?
A. Massage the uterine fundus until firm.
B. Administer an ordered oxytocic medication.
C. Notify the healthcare provider immediately.
D. Assist the client to the bathroom to void.
Correct Answer: D
Rationale: A fundus that is boggy and displaced to the right is a primary indicator of a
distended bladder. A full bladder prevents the uterus from contracting effectively, which
significantly increases the risk of postpartum hemorrhage. Assisting the client to void is the
priority intervention to allow the uterus to return to the midline and contract properly.
2. A newborn has a heart rate of 110 bpm, a weak cry, some flexion of the extremities,
grimaces when stimulated, and a pink body with blue extremities. What is the assigned
APGAR score?
A. 5
,B. 7
C. 6
D. 8
Correct Answer: C
Rationale: The score is calculated as follows: Heart rate >100 (2), weak cry (1), some
flexion (1), grimace (1), and acrocyanosis (1), totaling 6. APGAR scoring is performed at 1
and 5 minutes to assess the newborn’s immediate transition to extrauterine life. A score of
6 indicates moderate difficulty and requires close observation and potential intervention.
3. A client with preeclampsia is receiving an intravenous infusion of magnesium sulfate. The
nurse notes the client’s respiratory rate is 10 breaths/minute and deep tendon reflexes are
absent. Which medication should the nurse prepare?
A. Naloxone
B. Calcium gluconate
C. Protamine sulfate
D. Vitamin K
Correct Answer: B
Rationale: Calcium gluconate is the specific antidote for magnesium sulfate toxicity and
must be readily available at the bedside. The assessment findings of bradypnea and absent
reflexes are classic signs of magnesium overdose that require immediate reversal. The
,nurse must stop the infusion and notify the provider while preparing the antagonist to
prevent respiratory arrest.
4. Which clinical manifestation should a nurse expect to observe in a client diagnosed with
placenta previa?
A. Board-like, rigid abdomen
B. Severe, unrelenting abdominal pain
C. Dark red vaginal bleeding with contractions
D. Painless, bright red vaginal bleeding
Correct Answer: D
Rationale: Placenta previa is characterized by the painless onset of bright red vaginal
bleeding during the second or third trimester. This occurs because the placenta is
implanted over or near the cervical os, leading to bleeding as the cervix begins to dilate. In
contrast, abruptio placentae typically presents with painful bleeding and a rigid abdomen.
5. The nurse is providing teaching to a new mother about breastfeeding. Which statement by
the mother indicates a need for further instruction?
A. I should feed my baby every 2 to 3 hours.
B. I will wake my baby up to feed if it has been 4 hours.
C. I should ensure the baby has a large portion of the areola in their mouth.
D. I will wash my nipples with soap and water before every feed.
, Correct Answer: D
Rationale: Washing nipples with soap can lead to excessive dryness and cracking, which
increases the risk of infection and pain. Mothers are encouraged to use plain water or
expressed breast milk to clean the area instead. Proper latch technique and frequent
feeding intervals are essential components of successful lactation education.
6. A nurse is caring for a newborn immediately following birth. Which of the following is the
priority nursing action?
A. Administering erythromycin ophthalmic ointment.
B. Drying the infant and maintaining thermoregulation.
C. Applying the identification bands to the infant.
D. Administering the Vitamin K injection.
Correct Answer: B
Rationale: According to the ABCs and neonatal resuscitation guidelines, maintaining
airway and warmth are the highest priorities. Newborns are highly susceptible to cold
stress, which can lead to metabolic acidosis and respiratory distress. While identification
and medications are important, they are performed after the infant is stable and warm.
7. A nurse is teaching a parent of a 2-year-old child about safety. Which of the following
should be included in the teaching?
A. The child should be in a forward-facing car seat regardless of weight.
B. Store household cleaners in a low, unlocked cabinet for easy access.
