NUR2513/NUR 2513 Exam 4 V2 | Maternal-
Child Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is assessing a client who is at 35 weeks of gestation and is receiving magnesium
sulfate for severe preeclampsia. Which of the following findings should the nurse report to
the provider immediately?
A. Urine output of 40 mL/hr
B. Deep tendon reflexes of 2+
C. Respiratory rate of 10 breaths per minute
D. Blood pressure of 150/95 mmHg
Correct Answer: C
Rationale: A respiratory rate of less than 12 breaths per minute is a classic sign of
magnesium sulfate toxicity. Magnesium sulfate is a central nervous system depressant that
can cause respiratory arrest if levels become too high. The nurse must stop the infusion
immediately and notify the healthcare provider while preparing the antidote, calcium
gluconate.
2. A nurse is caring for a client who is in the first stage of labor and has a fetal heart rate
tracing showing late decelerations. Which of the following actions should the nurse take first?
A. Assist the client into a side-lying position
,B. Increase the IV fluid infusion rate
C. Administer oxygen at 10 L/min via nonrebreather mask
D. Notify the healthcare provider
Correct Answer: A
Rationale: Late decelerations are caused by uteroplacental insufficiency and indicate fetal
hypoxia. The first action the nurse should take is to improve blood flow to the placenta by
repositioning the mother to a side-lying position. Subsequent actions include increasing IV
fluids and administering oxygen, but position change is the priority intervention for
intrauterine resuscitation.
3. A nurse is preparing to administer terbutaline to a client who is experiencing preterm
labor. Which of the following findings is a contraindication for the administration of this
medication?
A. Uterine contractions every 5 minutes
B. Fetal heart rate of 150 beats per minute
C. Blood pressure of 110/70 mmHg
D. Maternal heart rate of 132 beats per minute
Correct Answer: D
Rationale: Terbutaline is a beta-adrenergic agonist that can cause significant tachycardia
and cardiac arrhythmias. It should be withheld if the maternal heart rate exceeds 120 beats
,per minute because it places excessive strain on the cardiovascular system. The nurse must
assess the heart rate prior to every dose and monitor for signs of pulmonary edema.
4. A nurse is assessing a newborn who was born at 32 weeks of gestation. Which of the
following findings should the nurse expect?
A. Prominent creases over the entire sole of the foot
B. Leathery, cracked skin
C. Presence of lanugo on the back and shoulders
D. Ears with firm cartilage and instant recoil
Correct Answer: C
Rationale: Lanugo, a fine downy hair, is abundant in preterm infants and usually
disappears as the fetus nears full term. Preterm infants often have smooth soles with few
creases and thin, translucent skin. Full-term or post-term infants would exhibit leathery
skin or firm ear cartilage with rapid recoil.
5. A client at 38 weeks of gestation presents with sudden, sharp abdominal pain and a board-
like abdomen without vaginal bleeding. Which of the following conditions should the nurse
suspect?
A. Abruptio placentae
B. Placenta previa
C. Cervical dilation
, D. False labor
Correct Answer: A
Rationale: Abruptio placentae is the premature separation of the placenta from the uterine
wall and can be concealed or visible. A rigid, board-like abdomen and intense pain are
hallmark signs of a concealed hemorrhage associated with abruption. This is a life-
threatening emergency for both the mother and the fetus requiring immediate surgical
intervention.
6. A nurse is caring for a 4-year-old child who has a new diagnosis of nephrotic syndrome.
Which of the following clinical manifestations should the nurse expect?
A. Severe periorbital edema
B. Gross hematuria
C. Hypolipidemia
D. Increased urine output
Correct Answer: A
Rationale: Nephrotic syndrome is characterized by massive proteinuria, which leads to
hypoalbuminemia and a shift of fluid into the interstitial spaces, causing edema. Periorbital
edema is a common initial finding that is often more prominent in the morning. Other
symptoms include hyperlipidemia and decreased urine output due to fluid retention.
Child Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is assessing a client who is at 35 weeks of gestation and is receiving magnesium
sulfate for severe preeclampsia. Which of the following findings should the nurse report to
the provider immediately?
A. Urine output of 40 mL/hr
B. Deep tendon reflexes of 2+
C. Respiratory rate of 10 breaths per minute
D. Blood pressure of 150/95 mmHg
Correct Answer: C
Rationale: A respiratory rate of less than 12 breaths per minute is a classic sign of
magnesium sulfate toxicity. Magnesium sulfate is a central nervous system depressant that
can cause respiratory arrest if levels become too high. The nurse must stop the infusion
immediately and notify the healthcare provider while preparing the antidote, calcium
gluconate.
2. A nurse is caring for a client who is in the first stage of labor and has a fetal heart rate
tracing showing late decelerations. Which of the following actions should the nurse take first?
A. Assist the client into a side-lying position
,B. Increase the IV fluid infusion rate
C. Administer oxygen at 10 L/min via nonrebreather mask
D. Notify the healthcare provider
Correct Answer: A
Rationale: Late decelerations are caused by uteroplacental insufficiency and indicate fetal
hypoxia. The first action the nurse should take is to improve blood flow to the placenta by
repositioning the mother to a side-lying position. Subsequent actions include increasing IV
fluids and administering oxygen, but position change is the priority intervention for
intrauterine resuscitation.
3. A nurse is preparing to administer terbutaline to a client who is experiencing preterm
labor. Which of the following findings is a contraindication for the administration of this
medication?
A. Uterine contractions every 5 minutes
B. Fetal heart rate of 150 beats per minute
C. Blood pressure of 110/70 mmHg
D. Maternal heart rate of 132 beats per minute
Correct Answer: D
Rationale: Terbutaline is a beta-adrenergic agonist that can cause significant tachycardia
and cardiac arrhythmias. It should be withheld if the maternal heart rate exceeds 120 beats
,per minute because it places excessive strain on the cardiovascular system. The nurse must
assess the heart rate prior to every dose and monitor for signs of pulmonary edema.
4. A nurse is assessing a newborn who was born at 32 weeks of gestation. Which of the
following findings should the nurse expect?
A. Prominent creases over the entire sole of the foot
B. Leathery, cracked skin
C. Presence of lanugo on the back and shoulders
D. Ears with firm cartilage and instant recoil
Correct Answer: C
Rationale: Lanugo, a fine downy hair, is abundant in preterm infants and usually
disappears as the fetus nears full term. Preterm infants often have smooth soles with few
creases and thin, translucent skin. Full-term or post-term infants would exhibit leathery
skin or firm ear cartilage with rapid recoil.
5. A client at 38 weeks of gestation presents with sudden, sharp abdominal pain and a board-
like abdomen without vaginal bleeding. Which of the following conditions should the nurse
suspect?
A. Abruptio placentae
B. Placenta previa
C. Cervical dilation
, D. False labor
Correct Answer: A
Rationale: Abruptio placentae is the premature separation of the placenta from the uterine
wall and can be concealed or visible. A rigid, board-like abdomen and intense pain are
hallmark signs of a concealed hemorrhage associated with abruption. This is a life-
threatening emergency for both the mother and the fetus requiring immediate surgical
intervention.
6. A nurse is caring for a 4-year-old child who has a new diagnosis of nephrotic syndrome.
Which of the following clinical manifestations should the nurse expect?
A. Severe periorbital edema
B. Gross hematuria
C. Hypolipidemia
D. Increased urine output
Correct Answer: A
Rationale: Nephrotic syndrome is characterized by massive proteinuria, which leads to
hypoalbuminemia and a shift of fluid into the interstitial spaces, causing edema. Periorbital
edema is a common initial finding that is often more prominent in the morning. Other
symptoms include hyperlipidemia and decreased urine output due to fluid retention.
