NUR2513/NUR 2513 Final Exam V3 |
Maternal-Child Nursing Q&A with
Rationale | Rasmussen University
1. A nurse is caring for a client at 34 weeks of gestation who presents with sudden, painless,
bright red vaginal bleeding. Which of the following conditions should the nurse suspect?
A. Abruptio placentae
B. Placenta previa
C. Ectopic pregnancy
D. Uterine rupture
Correct Answer: B
Rationale: Placenta previa is classically characterized by the onset of painless, bright red
vaginal bleeding during the second or third trimester. Unlike abruptio placentae, which
involves painful bleeding and uterine tenderness, previa occurs when the placenta covers
the cervical os. The nurse must avoid performing a vaginal examination until the location of
the placenta is confirmed by ultrasound.
2. A client with preeclampsia is receiving a continuous intravenous infusion of magnesium
sulfate. Which of the following findings should the nurse report to the provider as a sign of
toxicity?
A. Deep tendon reflexes of 2+
,B. Blood pressure of 150/95 mmHg
C. Urinary output of 40 mL/hr
D. Respiratory rate of 10/min
Correct Answer: D
Rationale: Magnesium sulfate toxicity leads to central nervous system depression,
evidenced by a respiratory rate below 12/min, loss of deep tendon reflexes, and decreased
urinary output. A respiratory rate of 10/min indicates significant depression and requires
immediate intervention. The nurse should stop the infusion and prepare the antidote,
calcium gluconate, for administration.
3. A nurse is assessing a newborn 1 minute after birth. The newborn has a heart rate of
110/min, a slow/weak cry, some flexion of the extremities, grimaces in response to
suctioning, and a pink body with blue extremities. What is the APGAR score?
A. 5
B. 6
C. 7
D. 8
Correct Answer: B
Rationale: The APGAR score is calculated as follows: Heart rate >100 (2), Respiratory
effort/cry is slow/weak (1), Muscle tone has some flexion (1), Reflex irritability shows a
,grimace (1), and Color shows acrocyanosis (1). Adding these points results in a total score
of 6. This score suggests that the newborn may require some resuscitation or close
monitoring during the initial transition period.
4. A nurse is monitoring a client in labor and observes late decelerations on the fetal heart
rate monitor. Which of the following actions should the nurse take first?
A. Administer oxygen via non-rebreather mask
B. Assist the client into a side-lying position
C. Increase the rate of the IV fluid infusion
D. Notify the healthcare provider
Correct Answer: B
Rationale: Late decelerations are indicative of uteroplacental insufficiency and require
immediate corrective action. Repositioning the client to a side-lying (lateral) position is the
priority to displace the uterus from the inferior vena cava and improve placental perfusion.
After repositioning, the nurse should proceed with other intrauterine resuscitation
measures such as oxygen administration and IV fluid boluses.
5. A postpartum nurse is assessing a client 2 hours after a vaginal delivery. The client’s fundus
is boggy and displaced to the right of the midline. Which of the following actions should the
nurse take?
A. Assist the client to the bathroom to void
B. Administer oxytocin intramuscularly
, C. Massage the fundus until firm
D. Notify the provider of a potential hemorrhage
Correct Answer: A
Rationale: A fundus that is displaced to the right and remains boggy is typically caused by
a distended bladder. A full bladder prevents the uterus from contracting effectively,
increasing the risk of postpartum hemorrhage. Assisting the client to void will allow the
uterus to return to the midline and contract properly, after which the nurse can reassess
the fundal tone.
6. A nurse is providing discharge teaching to the parents of a child with cystic fibrosis. Which
of the following should be included regarding nutrition?
A. Restrict salt intake to prevent edema
B. Administer pancreatic enzymes with all meals and snacks
C. Follow a low-calorie, low-fat diet
D. Limit fluid intake to reduce mucus production
Correct Answer: B
Rationale: Children with cystic fibrosis require pancreatic enzyme replacement therapy to
assist with the digestion and absorption of fats, proteins, and carbohydrates. These
enzymes must be taken with every meal and snack to prevent malabsorption and
steatorrhea. Additionally, these children usually require a high-calorie, high-protein diet
with increased salt intake, especially during hot weather.
Maternal-Child Nursing Q&A with
Rationale | Rasmussen University
1. A nurse is caring for a client at 34 weeks of gestation who presents with sudden, painless,
bright red vaginal bleeding. Which of the following conditions should the nurse suspect?
A. Abruptio placentae
B. Placenta previa
C. Ectopic pregnancy
D. Uterine rupture
Correct Answer: B
Rationale: Placenta previa is classically characterized by the onset of painless, bright red
vaginal bleeding during the second or third trimester. Unlike abruptio placentae, which
involves painful bleeding and uterine tenderness, previa occurs when the placenta covers
the cervical os. The nurse must avoid performing a vaginal examination until the location of
the placenta is confirmed by ultrasound.
2. A client with preeclampsia is receiving a continuous intravenous infusion of magnesium
sulfate. Which of the following findings should the nurse report to the provider as a sign of
toxicity?
A. Deep tendon reflexes of 2+
,B. Blood pressure of 150/95 mmHg
C. Urinary output of 40 mL/hr
D. Respiratory rate of 10/min
Correct Answer: D
Rationale: Magnesium sulfate toxicity leads to central nervous system depression,
evidenced by a respiratory rate below 12/min, loss of deep tendon reflexes, and decreased
urinary output. A respiratory rate of 10/min indicates significant depression and requires
immediate intervention. The nurse should stop the infusion and prepare the antidote,
calcium gluconate, for administration.
3. A nurse is assessing a newborn 1 minute after birth. The newborn has a heart rate of
110/min, a slow/weak cry, some flexion of the extremities, grimaces in response to
suctioning, and a pink body with blue extremities. What is the APGAR score?
A. 5
B. 6
C. 7
D. 8
Correct Answer: B
Rationale: The APGAR score is calculated as follows: Heart rate >100 (2), Respiratory
effort/cry is slow/weak (1), Muscle tone has some flexion (1), Reflex irritability shows a
,grimace (1), and Color shows acrocyanosis (1). Adding these points results in a total score
of 6. This score suggests that the newborn may require some resuscitation or close
monitoring during the initial transition period.
4. A nurse is monitoring a client in labor and observes late decelerations on the fetal heart
rate monitor. Which of the following actions should the nurse take first?
A. Administer oxygen via non-rebreather mask
B. Assist the client into a side-lying position
C. Increase the rate of the IV fluid infusion
D. Notify the healthcare provider
Correct Answer: B
Rationale: Late decelerations are indicative of uteroplacental insufficiency and require
immediate corrective action. Repositioning the client to a side-lying (lateral) position is the
priority to displace the uterus from the inferior vena cava and improve placental perfusion.
After repositioning, the nurse should proceed with other intrauterine resuscitation
measures such as oxygen administration and IV fluid boluses.
5. A postpartum nurse is assessing a client 2 hours after a vaginal delivery. The client’s fundus
is boggy and displaced to the right of the midline. Which of the following actions should the
nurse take?
A. Assist the client to the bathroom to void
B. Administer oxytocin intramuscularly
, C. Massage the fundus until firm
D. Notify the provider of a potential hemorrhage
Correct Answer: A
Rationale: A fundus that is displaced to the right and remains boggy is typically caused by
a distended bladder. A full bladder prevents the uterus from contracting effectively,
increasing the risk of postpartum hemorrhage. Assisting the client to void will allow the
uterus to return to the midline and contract properly, after which the nurse can reassess
the fundal tone.
6. A nurse is providing discharge teaching to the parents of a child with cystic fibrosis. Which
of the following should be included regarding nutrition?
A. Restrict salt intake to prevent edema
B. Administer pancreatic enzymes with all meals and snacks
C. Follow a low-calorie, low-fat diet
D. Limit fluid intake to reduce mucus production
Correct Answer: B
Rationale: Children with cystic fibrosis require pancreatic enzyme replacement therapy to
assist with the digestion and absorption of fats, proteins, and carbohydrates. These
enzymes must be taken with every meal and snack to prevent malabsorption and
steatorrhea. Additionally, these children usually require a high-calorie, high-protein diet
with increased salt intake, especially during hot weather.
