NUR2513/NUR 2513 Final Exam V2 |
Maternal-Child Nursing Q&A with
Rationale | Rasmussen University
1. A nurse is assessing a client who is at 34 weeks of gestation and has a diagnosis of
preeclampsia. Which of the following findings should the nurse report to the provider
immediately?
A. 1+ pitting edema in the lower extremities
B. Weight gain of 1 lb in one week
C. Blood pressure of 148/92 mm Hg
D. Epigastric pain
Correct Answer: D
Rationale: Epigastric pain is a sign of hepatic involvement and may indicate impending
hepatic rupture or eclampsia, which is a medical emergency. Mild pitting edema and a
blood pressure of 148/92 are characteristic of preeclampsia but are not as urgent as signs
of multi-organ failure. The nurse must prioritize signs that indicate a progression to HELLP
syndrome or seizure activity.
,2. A newborn’s heart rate is 110/min, they have a slow/weak cry, some flexion of the
extremities, grimace when flicked on the sole of the foot, and a pink body with blue
extremities. What is the APGAR score?
A. 5
B. 8
C. 7
D. 6
Correct Answer: D
Rationale: The score is calculated as follows: Heart rate >100 (2), slow/weak cry (1), some
flexion (1), grimace (1), and acrocyanosis (1), totaling 6. APGAR scoring is performed at 1
and 5 minutes after birth to assess the newborn’s transition to extrauterine life. A score of
6 indicates moderate distress and requires close monitoring and potential intervention.
3. Which of the following interventions is the priority for a nurse caring for a child
experiencing a sickle cell crisis?
A. Administering oral antibiotics
B. Applying cold compresses to painful joints
C. Maintaining aggressive intravenous hydration
D. Encouraging a high-protein diet
Correct Answer: C
, Rationale: Hydration is the priority because it helps reduce blood viscosity and prevents
further sickling of red blood cells. Cold compresses should be avoided as they cause
vasoconstriction, which can worsen the crisis. Pain management and oxygenation are also
critical, but fluid resuscitation is a cornerstone of acute crisis management.
4. A client at 32 weeks gestation presents with painless, bright red vaginal bleeding. Which of
the following conditions should the nurse suspect?
A. Abruptio placentae
B. Placenta previa
C. Preterm labor
D. Cervical insufficiency
Correct Answer: B
Rationale: Painless, bright red vaginal bleeding in the second or third trimester is the
classic sign of placenta previa. Conversely, abruptio placentae typically presents with
painful, dark red bleeding and uterine tenderness. The nurse must avoid performing a
vaginal exam on this client until the placental location is confirmed by ultrasound to avoid
hemorrhage.
5. The nurse is teaching the mother of a 2-year-old about safety. Which of the following
statements by the mother indicates a need for further teaching?
A. I will keep the pot handles turned toward the back of the stove.
B. I will put a gate at the top and bottom of the stairs.
Maternal-Child Nursing Q&A with
Rationale | Rasmussen University
1. A nurse is assessing a client who is at 34 weeks of gestation and has a diagnosis of
preeclampsia. Which of the following findings should the nurse report to the provider
immediately?
A. 1+ pitting edema in the lower extremities
B. Weight gain of 1 lb in one week
C. Blood pressure of 148/92 mm Hg
D. Epigastric pain
Correct Answer: D
Rationale: Epigastric pain is a sign of hepatic involvement and may indicate impending
hepatic rupture or eclampsia, which is a medical emergency. Mild pitting edema and a
blood pressure of 148/92 are characteristic of preeclampsia but are not as urgent as signs
of multi-organ failure. The nurse must prioritize signs that indicate a progression to HELLP
syndrome or seizure activity.
,2. A newborn’s heart rate is 110/min, they have a slow/weak cry, some flexion of the
extremities, grimace when flicked on the sole of the foot, and a pink body with blue
extremities. What is the APGAR score?
A. 5
B. 8
C. 7
D. 6
Correct Answer: D
Rationale: The score is calculated as follows: Heart rate >100 (2), slow/weak cry (1), some
flexion (1), grimace (1), and acrocyanosis (1), totaling 6. APGAR scoring is performed at 1
and 5 minutes after birth to assess the newborn’s transition to extrauterine life. A score of
6 indicates moderate distress and requires close monitoring and potential intervention.
3. Which of the following interventions is the priority for a nurse caring for a child
experiencing a sickle cell crisis?
A. Administering oral antibiotics
B. Applying cold compresses to painful joints
C. Maintaining aggressive intravenous hydration
D. Encouraging a high-protein diet
Correct Answer: C
, Rationale: Hydration is the priority because it helps reduce blood viscosity and prevents
further sickling of red blood cells. Cold compresses should be avoided as they cause
vasoconstriction, which can worsen the crisis. Pain management and oxygenation are also
critical, but fluid resuscitation is a cornerstone of acute crisis management.
4. A client at 32 weeks gestation presents with painless, bright red vaginal bleeding. Which of
the following conditions should the nurse suspect?
A. Abruptio placentae
B. Placenta previa
C. Preterm labor
D. Cervical insufficiency
Correct Answer: B
Rationale: Painless, bright red vaginal bleeding in the second or third trimester is the
classic sign of placenta previa. Conversely, abruptio placentae typically presents with
painful, dark red bleeding and uterine tenderness. The nurse must avoid performing a
vaginal exam on this client until the placental location is confirmed by ultrasound to avoid
hemorrhage.
5. The nurse is teaching the mother of a 2-year-old about safety. Which of the following
statements by the mother indicates a need for further teaching?
A. I will keep the pot handles turned toward the back of the stove.
B. I will put a gate at the top and bottom of the stairs.
