NUR2513/NUR 2513 Exam 4 V2 | Maternal
Child Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is caring for a patient diagnosed with severe preeclampsia who is receiving
intravenous Magnesium Sulfate. Which of the following findings should the nurse prioritize as
an indicator of magnesium toxicity?
A. Increased urinary output of 50 mL/hr
B. Blood pressure of 150/95 mmHg
C. Absent deep tendon reflexes
D. Respiratory rate of 14 breaths/min
Correct Answer: C
Rationale: Loss of deep tendon reflexes is a primary clinical indicator of magnesium
toxicity that precedes respiratory depression. The nurse must monitor for this sign to
prevent further central nervous system depression and potential cardiac arrest. Calcium
gluconate should be readily available as the antidote for this condition.
2. Which clinical manifestation is a classic sign of Pyloric Stenosis in an infant?
A. Projectile vomiting followed by hunger
B. Steatorrhea and abdominal distention
C. Currant jelly-like stools
,D. Painless bright red rectal bleeding
Correct Answer: A
Rationale: Projectile vomiting is the hallmark symptom of pyloric stenosis caused by the
hypertrophy of the pyloric sphincter. Infants typically remain hungry and eager to feed
immediately after vomiting episodes because the nutrition was never absorbed. An olive-
shaped mass may also be palpable in the epigastrium during physical examination.
3. A 4-year-old child is admitted with suspected Epiglottitis. Which nursing action is strictly
contraindicated for this patient?
A. Monitoring pulse oximetry continuously
B. Allowing the child to sit in a tripod position
C. Administering humidified oxygen
D. Obtaining a throat culture with a tongue blade
Correct Answer: D
Rationale: Attempting to visualize the throat or obtain a culture using a tongue blade can
trigger a complete laryngospasm. This represents a medical emergency that can lead to
total airway obstruction in seconds. Airway maintenance is the absolute priority, and the
child should never be left unattended until the airway is secured.
4. When assessing a newborn with Tetralogy of Fallot, the nurse notes the infant is
experiencing a ‘Tet spell.’ What is the priority nursing intervention?
A. Placing the infant in a knee-chest position
, B. Administering a dose of Digoxin
C. Preparing for immediate endotracheal intubation
D. Assessing the infant’s apical heart rate
Correct Answer: A
Rationale: The knee-chest position increases systemic vascular resistance, which helps
reduce the right-to-left shunt and improves oxygenation. This maneuver is the first-line
non-pharmacological intervention for acute cyanotic episodes in Tetralogy of Fallot.
Following this, the nurse may administer oxygen and morphine as prescribed to further
calm the infant and improve hemodynamics.
5. A postpartum nurse is monitoring a client who delivered 2 hours ago. The nurse notes the
fundus is boggy and displaced to the right. Which action should the nurse take first?
A. Massage the fundus until firm
B. Administer oxytocin IV bolus
C. Notify the healthcare provider immediately
D. Assist the client to the bathroom to void
Correct Answer: D
Rationale: A fundus that is displaced to the right typically indicates a distended bladder,
which prevents the uterus from contracting effectively. Emptying the bladder is the priority
Child Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is caring for a patient diagnosed with severe preeclampsia who is receiving
intravenous Magnesium Sulfate. Which of the following findings should the nurse prioritize as
an indicator of magnesium toxicity?
A. Increased urinary output of 50 mL/hr
B. Blood pressure of 150/95 mmHg
C. Absent deep tendon reflexes
D. Respiratory rate of 14 breaths/min
Correct Answer: C
Rationale: Loss of deep tendon reflexes is a primary clinical indicator of magnesium
toxicity that precedes respiratory depression. The nurse must monitor for this sign to
prevent further central nervous system depression and potential cardiac arrest. Calcium
gluconate should be readily available as the antidote for this condition.
2. Which clinical manifestation is a classic sign of Pyloric Stenosis in an infant?
A. Projectile vomiting followed by hunger
B. Steatorrhea and abdominal distention
C. Currant jelly-like stools
,D. Painless bright red rectal bleeding
Correct Answer: A
Rationale: Projectile vomiting is the hallmark symptom of pyloric stenosis caused by the
hypertrophy of the pyloric sphincter. Infants typically remain hungry and eager to feed
immediately after vomiting episodes because the nutrition was never absorbed. An olive-
shaped mass may also be palpable in the epigastrium during physical examination.
3. A 4-year-old child is admitted with suspected Epiglottitis. Which nursing action is strictly
contraindicated for this patient?
A. Monitoring pulse oximetry continuously
B. Allowing the child to sit in a tripod position
C. Administering humidified oxygen
D. Obtaining a throat culture with a tongue blade
Correct Answer: D
Rationale: Attempting to visualize the throat or obtain a culture using a tongue blade can
trigger a complete laryngospasm. This represents a medical emergency that can lead to
total airway obstruction in seconds. Airway maintenance is the absolute priority, and the
child should never be left unattended until the airway is secured.
4. When assessing a newborn with Tetralogy of Fallot, the nurse notes the infant is
experiencing a ‘Tet spell.’ What is the priority nursing intervention?
A. Placing the infant in a knee-chest position
, B. Administering a dose of Digoxin
C. Preparing for immediate endotracheal intubation
D. Assessing the infant’s apical heart rate
Correct Answer: A
Rationale: The knee-chest position increases systemic vascular resistance, which helps
reduce the right-to-left shunt and improves oxygenation. This maneuver is the first-line
non-pharmacological intervention for acute cyanotic episodes in Tetralogy of Fallot.
Following this, the nurse may administer oxygen and morphine as prescribed to further
calm the infant and improve hemodynamics.
5. A postpartum nurse is monitoring a client who delivered 2 hours ago. The nurse notes the
fundus is boggy and displaced to the right. Which action should the nurse take first?
A. Massage the fundus until firm
B. Administer oxytocin IV bolus
C. Notify the healthcare provider immediately
D. Assist the client to the bathroom to void
Correct Answer: D
Rationale: A fundus that is displaced to the right typically indicates a distended bladder,
which prevents the uterus from contracting effectively. Emptying the bladder is the priority
