NUR 230 Maternal & Pediatric Nursing Exam Prep 2026 |Galen College
1. A nurse is caring for a client who is at 36 weeks of gestation and has
preeclampsia. Which of the following findings should the nurse identify as a sign
of magnesium sulfate toxicity?
A. Increased urine output
B. Hyperreflexive deep tendon reflexes
C. Respiratory rate of 10/min
D. Fetal tachycardia
Answer: C
Rationale: Magnesium sulfate toxicity is characterized by respiratory depression (less
than 12/min), loss of deep tendon reflexes, and decreased urine output.
2. A nurse is assessing a 4-month-old infant. Which of the following
developmental milestones should the nurse expect the infant to have achieved?
A. Rolling from back to side
B. Using a pincer grasp
C. Sitting up without support
D. Walking while holding onto furniture
Answer: A
Rationale: By 4 months, infants typically roll from back to side. Sitting without support
occurs around 6 months, and pincer grasp around 9 months.
,3. A nurse is teaching a client about breastfeeding. Which of the following
statements by the client indicates an understanding of the teaching?
A. I will wash my nipples with soap before each feeding.
B. I should avoid using soap on my nipples to prevent drying and cracking.
C. I will help my baby latch by putting the tip of my nipple in their mouth.
D. I will ensure my baby’s nose, cheek, and chin are touching my breast.
D. I should wake my baby every 4 hours to feed.
Answer: B
Rationale: Correct latch involves the baby’s nose, cheek, and chin touching the breast. Soap
should be avoided as it dries the skin.
4. A nurse is caring for a client who is in the first stage of labor. The nurse
observes late decelerations on the fetal heart rate monitor. Which of the
following actions should the nurse take first?
A. Increase the rate of the maintenance IV fluid
B. Administer oxygen via nonrebreather mask
C. Assist the client into a left-lateral position
D. Notify the provider immediately
Answer: C
Rationale: Late decelerations indicate uteroplacental insufficiency. The first action is to
reposition the client to increase blood flow to the placenta.
, 5. A nurse is monitoring a newborn who was born 2 hours ago. Which of the
following findings should the nurse report to the provider?
A. Acrocyanosis
B. Milia on the bridge of the nose
C. Vernix caseosa in skin folds
D. Generalized petechiae
Answer: D
Rationale: Generalized petechiae can indicate a clotting factor deficiency or infection and
should be reported. Acrocyanosis and milia are normal findings.
6. A nurse is caring for a toddler who has a diagnosis of
laryngotracheobronchitis (croup). Which of the following findings is the priority
for the nurse to report?
A. Agitation and restlessness
B. Inspiratory stridor
C. Hoarseness
D. Barking cough
Answer: A
Rationale: Restlessness and agitation are early signs of hypoxia and airway obstruction,
making it the highest priority.
7. A nurse is teaching the parents of a child who has cystic fibrosis about
nutrition. Which of the following instructions should the nurse include?
A. Provide a low-fat, low-calorie diet.
B. Administer pancreatic enzymes with all meals and snacks.
C. Restrict salt intake during summer months.
D. Limit fluid intake to 1 liter per day.
Answer: B
1. A nurse is caring for a client who is at 36 weeks of gestation and has
preeclampsia. Which of the following findings should the nurse identify as a sign
of magnesium sulfate toxicity?
A. Increased urine output
B. Hyperreflexive deep tendon reflexes
C. Respiratory rate of 10/min
D. Fetal tachycardia
Answer: C
Rationale: Magnesium sulfate toxicity is characterized by respiratory depression (less
than 12/min), loss of deep tendon reflexes, and decreased urine output.
2. A nurse is assessing a 4-month-old infant. Which of the following
developmental milestones should the nurse expect the infant to have achieved?
A. Rolling from back to side
B. Using a pincer grasp
C. Sitting up without support
D. Walking while holding onto furniture
Answer: A
Rationale: By 4 months, infants typically roll from back to side. Sitting without support
occurs around 6 months, and pincer grasp around 9 months.
,3. A nurse is teaching a client about breastfeeding. Which of the following
statements by the client indicates an understanding of the teaching?
A. I will wash my nipples with soap before each feeding.
B. I should avoid using soap on my nipples to prevent drying and cracking.
C. I will help my baby latch by putting the tip of my nipple in their mouth.
D. I will ensure my baby’s nose, cheek, and chin are touching my breast.
D. I should wake my baby every 4 hours to feed.
Answer: B
Rationale: Correct latch involves the baby’s nose, cheek, and chin touching the breast. Soap
should be avoided as it dries the skin.
4. A nurse is caring for a client who is in the first stage of labor. The nurse
observes late decelerations on the fetal heart rate monitor. Which of the
following actions should the nurse take first?
A. Increase the rate of the maintenance IV fluid
B. Administer oxygen via nonrebreather mask
C. Assist the client into a left-lateral position
D. Notify the provider immediately
Answer: C
Rationale: Late decelerations indicate uteroplacental insufficiency. The first action is to
reposition the client to increase blood flow to the placenta.
, 5. A nurse is monitoring a newborn who was born 2 hours ago. Which of the
following findings should the nurse report to the provider?
A. Acrocyanosis
B. Milia on the bridge of the nose
C. Vernix caseosa in skin folds
D. Generalized petechiae
Answer: D
Rationale: Generalized petechiae can indicate a clotting factor deficiency or infection and
should be reported. Acrocyanosis and milia are normal findings.
6. A nurse is caring for a toddler who has a diagnosis of
laryngotracheobronchitis (croup). Which of the following findings is the priority
for the nurse to report?
A. Agitation and restlessness
B. Inspiratory stridor
C. Hoarseness
D. Barking cough
Answer: A
Rationale: Restlessness and agitation are early signs of hypoxia and airway obstruction,
making it the highest priority.
7. A nurse is teaching the parents of a child who has cystic fibrosis about
nutrition. Which of the following instructions should the nurse include?
A. Provide a low-fat, low-calorie diet.
B. Administer pancreatic enzymes with all meals and snacks.
C. Restrict salt intake during summer months.
D. Limit fluid intake to 1 liter per day.
Answer: B
