NUR2513 Exam 2 Questions and Correct Answers with Explanation |
Latest Update | Rasmussen University
1. A nurse is monitoring a fetal heart rate (FHR) tracing and notes a pattern of
variable decelerations. Which of the following is the most likely cause?
A. Head compression
B. Uteroplacental insufficiency
C. Fetal sleep cycle
D. Umbilical cord compression
Answer: D
Explanation: Variable decelerations are typically caused by umbilical cord compression.
Head compression causes early decelerations, and uteroplacental insufficiency causes late
decelerations.
2. A client at 34 weeks gestation is receiving magnesium sulfate for
preeclampsia. Which assessment finding should the nurse report immediately?
A. Respiratory rate of 10 breaths per minute
B. Flushing and feeling warm
C. Deep tendon reflexes of 2+
D. Urine output of 40 mL/hr
Answer: A
,Explanation: A respiratory rate below 12 per minute is a sign of magnesium sulfate
toxicity. Other signs include loss of deep tendon reflexes and decreased urine output (less
than 30 mL/hr).
3. During the active phase of the first stage of labor, a client’s cervix is dilated to
5 cm. Which of the following nursing actions is appropriate?
A. Encourage the client to push with contractions
B. Assist the client with breathing techniques
C. Perform a vaginal exam every 15 minutes
D. Prepare for the delivery of the placenta
Answer: B
Explanation: During the first stage (active phase), the nurse helps the client manage pain
through breathing and positioning. Pushing only occurs in the second stage.
4. Which medication is the antidote for magnesium sulfate toxicity?
A. Naloxone
B. Terbutaline
C. Calcium gluconate
D. Oxytocin
Answer: C
Explanation: Calcium gluconate is the specific antidote to reverse the effects of magnesium
sulfate toxicity.
,5. A nurse is caring for a client who is in the fourth stage of labor. Which of the
following is a priority nursing assessment?
A. Fetal heart rate
B. Cervical dilation
C. Fundal firmness and position
D. Apgar score
Answer: C
Explanation: The fourth stage of labor is the first 1-2 hours after delivery. The priority is
assessing for postpartum hemorrhage by checking the fundus and lochia.
6. A nurse is assessing a newborn 1 minute after birth and finds: HR 110,
slow/irregular cry, some flexion of extremities, grimace when suctioned, and
body pink with blue extremities. What is the Apgar score?
A. 5
B. 6
C. 7
D. 8
Answer: B
Explanation: HR > 100 (2), Respiratory effort slow (1), Muscle tone some flexion (1),
Reflex grimace (1), Color acrocyanosis (1). Total = 6.
, 7. Which of the following is a symptom of Abruptio Placentae?
A. Sudden onset of dark red bleeding and board-like abdomen
B. Soft, non-tender abdomen
C. Painless, bright red vaginal bleeding
D. Increased fetal movement
Answer: A
Explanation: Abruptio Placentae is characterized by painful, dark red bleeding and uterine
tenderness or a ‘board-like’ abdomen. Painless bleeding is associated with Placenta Previa.
8. A nurse is preparing to administer Vitamin K to a newborn. What is the
primary purpose of this medication?
A. To prevent ophthalmia neonatorum
B. To prevent hemorrhagic disease of the newborn
C. To stimulate surfactant production
D. To treat physiological jaundice
Answer: B
Explanation: Newborns are born with low Vitamin K levels because it does not cross the
placenta and the sterile gut hasn’t produced it yet; Vitamin K is essential for clotting.
Latest Update | Rasmussen University
1. A nurse is monitoring a fetal heart rate (FHR) tracing and notes a pattern of
variable decelerations. Which of the following is the most likely cause?
A. Head compression
B. Uteroplacental insufficiency
C. Fetal sleep cycle
D. Umbilical cord compression
Answer: D
Explanation: Variable decelerations are typically caused by umbilical cord compression.
Head compression causes early decelerations, and uteroplacental insufficiency causes late
decelerations.
2. A client at 34 weeks gestation is receiving magnesium sulfate for
preeclampsia. Which assessment finding should the nurse report immediately?
A. Respiratory rate of 10 breaths per minute
B. Flushing and feeling warm
C. Deep tendon reflexes of 2+
D. Urine output of 40 mL/hr
Answer: A
,Explanation: A respiratory rate below 12 per minute is a sign of magnesium sulfate
toxicity. Other signs include loss of deep tendon reflexes and decreased urine output (less
than 30 mL/hr).
3. During the active phase of the first stage of labor, a client’s cervix is dilated to
5 cm. Which of the following nursing actions is appropriate?
A. Encourage the client to push with contractions
B. Assist the client with breathing techniques
C. Perform a vaginal exam every 15 minutes
D. Prepare for the delivery of the placenta
Answer: B
Explanation: During the first stage (active phase), the nurse helps the client manage pain
through breathing and positioning. Pushing only occurs in the second stage.
4. Which medication is the antidote for magnesium sulfate toxicity?
A. Naloxone
B. Terbutaline
C. Calcium gluconate
D. Oxytocin
Answer: C
Explanation: Calcium gluconate is the specific antidote to reverse the effects of magnesium
sulfate toxicity.
,5. A nurse is caring for a client who is in the fourth stage of labor. Which of the
following is a priority nursing assessment?
A. Fetal heart rate
B. Cervical dilation
C. Fundal firmness and position
D. Apgar score
Answer: C
Explanation: The fourth stage of labor is the first 1-2 hours after delivery. The priority is
assessing for postpartum hemorrhage by checking the fundus and lochia.
6. A nurse is assessing a newborn 1 minute after birth and finds: HR 110,
slow/irregular cry, some flexion of extremities, grimace when suctioned, and
body pink with blue extremities. What is the Apgar score?
A. 5
B. 6
C. 7
D. 8
Answer: B
Explanation: HR > 100 (2), Respiratory effort slow (1), Muscle tone some flexion (1),
Reflex grimace (1), Color acrocyanosis (1). Total = 6.
, 7. Which of the following is a symptom of Abruptio Placentae?
A. Sudden onset of dark red bleeding and board-like abdomen
B. Soft, non-tender abdomen
C. Painless, bright red vaginal bleeding
D. Increased fetal movement
Answer: A
Explanation: Abruptio Placentae is characterized by painful, dark red bleeding and uterine
tenderness or a ‘board-like’ abdomen. Painless bleeding is associated with Placenta Previa.
8. A nurse is preparing to administer Vitamin K to a newborn. What is the
primary purpose of this medication?
A. To prevent ophthalmia neonatorum
B. To prevent hemorrhagic disease of the newborn
C. To stimulate surfactant production
D. To treat physiological jaundice
Answer: B
Explanation: Newborns are born with low Vitamin K levels because it does not cross the
placenta and the sterile gut hasn’t produced it yet; Vitamin K is essential for clotting.
