NUR 254 Exam 4: Maternal and Pediatrics - Galen College
of Nursing Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is caring for a client at 34 weeks gestation who presents with sudden, dark red vaginal bleeding
and intense abdominal pain. Which condition should the nurse suspect?
A. Placenta previa
B. Cervical insufficiency
C. Abruptio placentae
D. Hydatidiform mole
Correct Answer: C
Rationale: Abruptio placentae is characterized by painful, dark red vaginal bleeding due to the
premature separation of the placenta from the uterine wall. In contrast, placenta previa typically involves
painless, bright red bleeding. The intensity of the abdominal pain and uterine tenderness are hallmark
signs of an abruption. Immediate nursing assessment of fetal well-being and maternal hemodynamic
stability is crucial. This condition is a medical emergency that often requires rapid delivery to prevent
maternal and fetal morbidity.
2. A 2-year-old child is admitted to the pediatric unit with suspected bacterial meningitis. Which clinical
manifestation should the nurse prioritize during assessment?
A. Increased appetite and thirst
B. Presence of a positive Brudzinski sign
C. Sunken anterior fontanel
D. Bradycardia and hypotension
,Correct Answer: B
Rationale: A positive Brudzinski sign, where neck flexion causes involuntary hip and knee flexion,
indicates meningeal irritation. This is a classic finding in bacterial meningitis for children over the age of
infancy. Other signs include nuchal rigidity, high fever, and a bulging (not sunken) fontanel in infants.
Rapid identification of these neurological signs is vital for starting timely antibiotic therapy. The nurse
must also monitor for signs of increased intracranial pressure as the infection progresses.
3. A postpartum nurse is assessing a client 2 hours after delivery and finds the fundus is boggy and displaced
to the right. What is the nurse’s priority action?
A. Administer oxytocin immediately
B. Assist the client to the bathroom to void
C. Notify the provider of potential hemorrhage
D. Perform vigorous fundal massage
Correct Answer: B
Rationale: A displaced and boggy fundus is most often caused by a full bladder preventing effective
uterine contraction. Assisting the client to empty their bladder allows the uterus to return to the midline
and contract properly. While fundal massage is important, it will not resolve the issue if the bladder
remains distended. After voiding, the nurse should reassess the fundal position and tone to ensure
stability. Preventing bladder distention is a key intervention in managing the risk of postpartum
hemorrhage.
4. A nurse is teaching the parents of a child with Tetralogy of Fallot how to manage a hypercyanotic (Tet)
spell. Which instruction is most important?
A. Offer a bottle to soothe the infant
, B. Place the child in a knee-chest position
C. Begin chest compressions immediately
D. Encourage the child to take deep breaths
Correct Answer: B
Rationale: The knee-chest position increases systemic vascular resistance, which helps shunt blood into
the pulmonary artery rather than through the ventricular septal defect. This maneuver improves
oxygenation and decreases the right-to-left shunt during an acute cyanotic episode. Parents should be
taught to recognize the onset of a spell and act quickly to reposition the child. Comforting the child is also
important to reduce oxygen demand, but the physical maneuver is the priority. Medical follow-up is
necessary after any significant hypercyanotic event.
5. Which laboratory result would the nurse expect for a client diagnosed with HELLP syndrome?
A. Elevated hemoglobin and hematocrit
B. Platelet count of 75,000/mm³
C. Decreased liver enzymes (AST/ALT)
D. Reduced serum creatinine levels
Correct Answer: B
Rationale: HELLP syndrome is defined by Hemolysis, Elevated Liver enzymes, and Low Platelets. A
platelet count of 75,000/mm³ is significantly below the normal range and fits the diagnostic criteria.
Hemolysis would typically lead to decreased hemoglobin rather than an elevation. Elevated liver enzymes
would also be present due to hepatic involvement and tissue damage. Close monitoring of coagulation
profiles and liver function is essential for these high-risk obstetric patients.
of Nursing Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is caring for a client at 34 weeks gestation who presents with sudden, dark red vaginal bleeding
and intense abdominal pain. Which condition should the nurse suspect?
A. Placenta previa
B. Cervical insufficiency
C. Abruptio placentae
D. Hydatidiform mole
Correct Answer: C
Rationale: Abruptio placentae is characterized by painful, dark red vaginal bleeding due to the
premature separation of the placenta from the uterine wall. In contrast, placenta previa typically involves
painless, bright red bleeding. The intensity of the abdominal pain and uterine tenderness are hallmark
signs of an abruption. Immediate nursing assessment of fetal well-being and maternal hemodynamic
stability is crucial. This condition is a medical emergency that often requires rapid delivery to prevent
maternal and fetal morbidity.
2. A 2-year-old child is admitted to the pediatric unit with suspected bacterial meningitis. Which clinical
manifestation should the nurse prioritize during assessment?
A. Increased appetite and thirst
B. Presence of a positive Brudzinski sign
C. Sunken anterior fontanel
D. Bradycardia and hypotension
,Correct Answer: B
Rationale: A positive Brudzinski sign, where neck flexion causes involuntary hip and knee flexion,
indicates meningeal irritation. This is a classic finding in bacterial meningitis for children over the age of
infancy. Other signs include nuchal rigidity, high fever, and a bulging (not sunken) fontanel in infants.
Rapid identification of these neurological signs is vital for starting timely antibiotic therapy. The nurse
must also monitor for signs of increased intracranial pressure as the infection progresses.
3. A postpartum nurse is assessing a client 2 hours after delivery and finds the fundus is boggy and displaced
to the right. What is the nurse’s priority action?
A. Administer oxytocin immediately
B. Assist the client to the bathroom to void
C. Notify the provider of potential hemorrhage
D. Perform vigorous fundal massage
Correct Answer: B
Rationale: A displaced and boggy fundus is most often caused by a full bladder preventing effective
uterine contraction. Assisting the client to empty their bladder allows the uterus to return to the midline
and contract properly. While fundal massage is important, it will not resolve the issue if the bladder
remains distended. After voiding, the nurse should reassess the fundal position and tone to ensure
stability. Preventing bladder distention is a key intervention in managing the risk of postpartum
hemorrhage.
4. A nurse is teaching the parents of a child with Tetralogy of Fallot how to manage a hypercyanotic (Tet)
spell. Which instruction is most important?
A. Offer a bottle to soothe the infant
, B. Place the child in a knee-chest position
C. Begin chest compressions immediately
D. Encourage the child to take deep breaths
Correct Answer: B
Rationale: The knee-chest position increases systemic vascular resistance, which helps shunt blood into
the pulmonary artery rather than through the ventricular septal defect. This maneuver improves
oxygenation and decreases the right-to-left shunt during an acute cyanotic episode. Parents should be
taught to recognize the onset of a spell and act quickly to reposition the child. Comforting the child is also
important to reduce oxygen demand, but the physical maneuver is the priority. Medical follow-up is
necessary after any significant hypercyanotic event.
5. Which laboratory result would the nurse expect for a client diagnosed with HELLP syndrome?
A. Elevated hemoglobin and hematocrit
B. Platelet count of 75,000/mm³
C. Decreased liver enzymes (AST/ALT)
D. Reduced serum creatinine levels
Correct Answer: B
Rationale: HELLP syndrome is defined by Hemolysis, Elevated Liver enzymes, and Low Platelets. A
platelet count of 75,000/mm³ is significantly below the normal range and fits the diagnostic criteria.
Hemolysis would typically lead to decreased hemoglobin rather than an elevation. Elevated liver enzymes
would also be present due to hepatic involvement and tissue damage. Close monitoring of coagulation
profiles and liver function is essential for these high-risk obstetric patients.
