NUR2513/NUR 2513 Final Exam V2 |
Maternal Child Nursing Q&A with
Rationale | Rasmussen University
1. A nurse is monitoring a client who is receiving magnesium sulfate for the treatment of
preeclampsia. Which of the following findings should the nurse identify as an early sign of
magnesium toxicity?
A. Increased urinary output
B. Diminished deep tendon reflexes
C. Hyperactive deep tendon reflexes
D. Generalized skin flushing
Correct Answer: B
Rationale: Diminished or absent deep tendon reflexes (DTRs) are an early clinical
manifestation of magnesium toxicity. The nurse must also monitor for a respiratory rate
below 12 breaths per minute and decreased urine output. Calcium gluconate is the
standard antidote and should be readily available at the bedside for immediate
administration.
,2. A nurse is assessing a newborn 1 minute after birth and notes the following: heart rate
110/min, slow/weak cry, some flexion of extremities, grimace when suctioned, and body pink
with blue extremities. What APGAR score should the nurse assign?
A. 6
B. 5
C. 7
D. 8
Correct Answer: A
Rationale: The score is calculated as follows: 2 points for HR >100, 1 point for slow cry, 1
point for flexion, 1 point for grimace, and 1 point for acrocyanosis. This results in a total
score of 6, which indicates moderate distress. The nurse should continue to monitor the
newborn and repeat the assessment at the 5-minute mark to evaluate improvement.
3. A nurse is caring for a client who is at 32 weeks of gestation and experiencing preterm
labor. Which of the following medications should the nurse expect to administer to promote
fetal lung maturity?
A. Betamethasone
B. Terbutaline
C. Indomethacin
D. Nifedipine
,Correct Answer: A
Rationale: Betamethasone is a glucocorticoid administered via intramuscular injection to
stimulate surfactant production in the fetal lungs. This intervention is critical for reducing
the risk of respiratory distress syndrome in infants born prematurely. While other
medications like Nifedipine may be used to halt contractions, Betamethasone specifically
addresses fetal maturity.
4. A nurse is educating a parent of a 4-year-old child about appropriate play activities.
According to Piaget, which stage of cognitive development is this child in?
A. Sensorimotor
B. Preoperational
C. Concrete operational
D. Formal operational
Correct Answer: B
Rationale: Children aged 2 to 7 years are in the preoperational stage, characterized by
symbolic thinking and egocentrism. During this stage, children often engage in make-
believe play and have difficulty understanding the perspectives of others. Nurses should
tailor education to include simple language and use medical play to reduce anxiety.
, 5. A nurse is performing a postpartum assessment on a client who delivered 4 hours ago. The
nurse notes the fundus is boggy and displaced to the right. Which action should the nurse
take first?
A. Assist the client to void
B. Massage the fundus
C. Administer oxytocin
D. Notify the provider
Correct Answer: A
Rationale: A fundus that is displaced to the right and boggy typically indicates a distended
bladder, which prevents the uterus from contracting effectively. Assisting the client to void
is the priority intervention to allow the uterus to return to the midline and firm up. If the
fundus remains boggy after voiding, the nurse should then perform fundal massage to
prevent postpartum hemorrhage.
6. A nurse is caring for an infant who has developmental dysplasia of the hip (DDH). Which of
the following clinical manifestations should the nurse expect?
A. Positive Ortolani test
B. Lengthening of the affected limb
C. Symmetrical gluteal folds
D. Inward rotation of the affected foot
Maternal Child Nursing Q&A with
Rationale | Rasmussen University
1. A nurse is monitoring a client who is receiving magnesium sulfate for the treatment of
preeclampsia. Which of the following findings should the nurse identify as an early sign of
magnesium toxicity?
A. Increased urinary output
B. Diminished deep tendon reflexes
C. Hyperactive deep tendon reflexes
D. Generalized skin flushing
Correct Answer: B
Rationale: Diminished or absent deep tendon reflexes (DTRs) are an early clinical
manifestation of magnesium toxicity. The nurse must also monitor for a respiratory rate
below 12 breaths per minute and decreased urine output. Calcium gluconate is the
standard antidote and should be readily available at the bedside for immediate
administration.
,2. A nurse is assessing a newborn 1 minute after birth and notes the following: heart rate
110/min, slow/weak cry, some flexion of extremities, grimace when suctioned, and body pink
with blue extremities. What APGAR score should the nurse assign?
A. 6
B. 5
C. 7
D. 8
Correct Answer: A
Rationale: The score is calculated as follows: 2 points for HR >100, 1 point for slow cry, 1
point for flexion, 1 point for grimace, and 1 point for acrocyanosis. This results in a total
score of 6, which indicates moderate distress. The nurse should continue to monitor the
newborn and repeat the assessment at the 5-minute mark to evaluate improvement.
3. A nurse is caring for a client who is at 32 weeks of gestation and experiencing preterm
labor. Which of the following medications should the nurse expect to administer to promote
fetal lung maturity?
A. Betamethasone
B. Terbutaline
C. Indomethacin
D. Nifedipine
,Correct Answer: A
Rationale: Betamethasone is a glucocorticoid administered via intramuscular injection to
stimulate surfactant production in the fetal lungs. This intervention is critical for reducing
the risk of respiratory distress syndrome in infants born prematurely. While other
medications like Nifedipine may be used to halt contractions, Betamethasone specifically
addresses fetal maturity.
4. A nurse is educating a parent of a 4-year-old child about appropriate play activities.
According to Piaget, which stage of cognitive development is this child in?
A. Sensorimotor
B. Preoperational
C. Concrete operational
D. Formal operational
Correct Answer: B
Rationale: Children aged 2 to 7 years are in the preoperational stage, characterized by
symbolic thinking and egocentrism. During this stage, children often engage in make-
believe play and have difficulty understanding the perspectives of others. Nurses should
tailor education to include simple language and use medical play to reduce anxiety.
, 5. A nurse is performing a postpartum assessment on a client who delivered 4 hours ago. The
nurse notes the fundus is boggy and displaced to the right. Which action should the nurse
take first?
A. Assist the client to void
B. Massage the fundus
C. Administer oxytocin
D. Notify the provider
Correct Answer: A
Rationale: A fundus that is displaced to the right and boggy typically indicates a distended
bladder, which prevents the uterus from contracting effectively. Assisting the client to void
is the priority intervention to allow the uterus to return to the midline and firm up. If the
fundus remains boggy after voiding, the nurse should then perform fundal massage to
prevent postpartum hemorrhage.
6. A nurse is caring for an infant who has developmental dysplasia of the hip (DDH). Which of
the following clinical manifestations should the nurse expect?
A. Positive Ortolani test
B. Lengthening of the affected limb
C. Symmetrical gluteal folds
D. Inward rotation of the affected foot
