NUR2513 Maternal-Child Nursing Final Exam Questions and Correct
Answers with Explanation | Latest Update | Rasmussen University
1. A nurse is assessing a newborn at 1 minute after birth. The heart rate is 110
bpm, the infant has a vigorous cry, some flexion of extremities, sneezes when
stimulated, and the body is pink with blue extremities. What is the APGAR
score?
A. 7
B. 8
C. 9
D. 10
Answer: B
Explanation: The score is 8: Heart rate >100 (2), vigorous cry (2), some flexion (1), sneeze
(2), and acrocyanosis (1).
2. A client at 34 weeks gestation is receiving magnesium sulfate for
preeclampsia. Which finding should the nurse report to the provider
immediately?
A. Sluggish deep tendon reflexes
B. Urine output of 20 mL/hr
C. Respiratory rate of 14/min
,D. Feeling of warmth and flushing
Answer: B
Explanation: Urine output less than 30 mL/hr can indicate magnesium toxicity as the drug
is excreted by the kidneys. Sluggish reflexes and low respirations are also signs, but urine
output is a critical early indicator of decreased excretion.
3. Which of the following is a classic sign of placenta previa?
A. Hard, board-like abdomen
B. Painful vaginal bleeding
C. Persistent low back pain
D. Painless, bright red vaginal bleeding
Answer: D
Explanation: Placenta previa is characterized by painless, bright red bleeding. Painful
bleeding and a board-like abdomen are associated with abruptio placentae.
4. A nurse is caring for a client in the second stage of labor. Which of the
following manifestations should the nurse expect?
A. The client feels an urge to push
B. The cervix is dilating from 4 to 7 cm
C. The placenta is being delivered
D. The client is in the latent phase of labor
Answer: A
,Explanation: The second stage of labor begins with full cervical dilation and ends with the
birth of the baby; the Ferguson reflex (urge to push) occurs during this stage.
5. A postpartum client is experiencing heavy vaginal bleeding and a boggy
uterus. What is the priority nursing action?
A. Administer oxytocin IV
B. Notify the healthcare provider
C. Perform fundal massage
D. Encourage the client to void
Answer: C
Explanation: The first action for a boggy uterus and heavy bleeding is to perform fundal
massage to stimulate uterine contractions and stop the bleeding.
6. The nurse observes late decelerations on the fetal monitor. Which action
should the nurse take first?
A. Assist the client to a knee-chest position
B. Turn the client to a side-lying position
C. Apply oxygen at 8 to 10 L/min via nonrebreather mask
D. Increase the rate of the IV fluid
Answer: B
Explanation: The priority action for late decelerations is to improve placental perfusion by
turning the client to their side. Oxygen and fluids follow.
, 7. Which reflex is elicited by touching the newborn’s cheek?
A. Moro reflex
B. Babinski reflex
C. Palmar grasp reflex
D. Rooting reflex
Answer: D
Explanation: The rooting reflex is elicited when the cheek or side of the mouth is touched,
causing the infant to turn the head toward that side.
8. A newborn is receiving phototherapy for hyperbilirubinemia. Which nursing
intervention is essential?
A. Apply lotion to the skin every 2 hours
B. Limit fluid intake to prevent diarrhea
C. Cover the newborn’s eyes with a mask
D. Keep the infant in a prone position
Answer: C
Explanation: Protective eye masks are required during phototherapy to prevent damage
to the infant’s retinas.
9. According to Erikson, which developmental task is primary for a toddler?
A. Autonomy vs. Shame and Doubt
B. Industry vs. Inferiority
Answers with Explanation | Latest Update | Rasmussen University
1. A nurse is assessing a newborn at 1 minute after birth. The heart rate is 110
bpm, the infant has a vigorous cry, some flexion of extremities, sneezes when
stimulated, and the body is pink with blue extremities. What is the APGAR
score?
A. 7
B. 8
C. 9
D. 10
Answer: B
Explanation: The score is 8: Heart rate >100 (2), vigorous cry (2), some flexion (1), sneeze
(2), and acrocyanosis (1).
2. A client at 34 weeks gestation is receiving magnesium sulfate for
preeclampsia. Which finding should the nurse report to the provider
immediately?
A. Sluggish deep tendon reflexes
B. Urine output of 20 mL/hr
C. Respiratory rate of 14/min
,D. Feeling of warmth and flushing
Answer: B
Explanation: Urine output less than 30 mL/hr can indicate magnesium toxicity as the drug
is excreted by the kidneys. Sluggish reflexes and low respirations are also signs, but urine
output is a critical early indicator of decreased excretion.
3. Which of the following is a classic sign of placenta previa?
A. Hard, board-like abdomen
B. Painful vaginal bleeding
C. Persistent low back pain
D. Painless, bright red vaginal bleeding
Answer: D
Explanation: Placenta previa is characterized by painless, bright red bleeding. Painful
bleeding and a board-like abdomen are associated with abruptio placentae.
4. A nurse is caring for a client in the second stage of labor. Which of the
following manifestations should the nurse expect?
A. The client feels an urge to push
B. The cervix is dilating from 4 to 7 cm
C. The placenta is being delivered
D. The client is in the latent phase of labor
Answer: A
,Explanation: The second stage of labor begins with full cervical dilation and ends with the
birth of the baby; the Ferguson reflex (urge to push) occurs during this stage.
5. A postpartum client is experiencing heavy vaginal bleeding and a boggy
uterus. What is the priority nursing action?
A. Administer oxytocin IV
B. Notify the healthcare provider
C. Perform fundal massage
D. Encourage the client to void
Answer: C
Explanation: The first action for a boggy uterus and heavy bleeding is to perform fundal
massage to stimulate uterine contractions and stop the bleeding.
6. The nurse observes late decelerations on the fetal monitor. Which action
should the nurse take first?
A. Assist the client to a knee-chest position
B. Turn the client to a side-lying position
C. Apply oxygen at 8 to 10 L/min via nonrebreather mask
D. Increase the rate of the IV fluid
Answer: B
Explanation: The priority action for late decelerations is to improve placental perfusion by
turning the client to their side. Oxygen and fluids follow.
, 7. Which reflex is elicited by touching the newborn’s cheek?
A. Moro reflex
B. Babinski reflex
C. Palmar grasp reflex
D. Rooting reflex
Answer: D
Explanation: The rooting reflex is elicited when the cheek or side of the mouth is touched,
causing the infant to turn the head toward that side.
8. A newborn is receiving phototherapy for hyperbilirubinemia. Which nursing
intervention is essential?
A. Apply lotion to the skin every 2 hours
B. Limit fluid intake to prevent diarrhea
C. Cover the newborn’s eyes with a mask
D. Keep the infant in a prone position
Answer: C
Explanation: Protective eye masks are required during phototherapy to prevent damage
to the infant’s retinas.
9. According to Erikson, which developmental task is primary for a toddler?
A. Autonomy vs. Shame and Doubt
B. Industry vs. Inferiority
