NUR2513/NUR 2513 Final Exam V1 |
Maternal-Child Nursing Q&A with
Rationale | Rasmussen University
1. A nurse is assessing a pregnant client at 34 weeks gestation who presents with sudden,
painless vaginal bleeding. Which condition should the nurse suspect?
A. Abruptio placentae
B. Hydatidiform mole
C. Cervical insufficiency
D. Placenta previa
Correct Answer: D
Rationale: Placenta previa is characterized by the sudden onset of painless, bright red
vaginal bleeding in the second or third trimester. Unlike placental abruption, which
involves painful bleeding and uterine rigidity, placenta previa is typically painless because
the placenta is simply covering the internal os. The nurse must avoid performing a vaginal
exam until the placental location is confirmed by ultrasound to prevent hemorrhage.
2. Which of the following interventions is the priority for a nurse caring for a newborn
immediately after birth?
A. Administering Vitamin K intramuscularly
B. Applying erythromycin ophthalmic ointment
,C. Drying the infant and maintaining thermoregulation
D. Performing the initial physical assessment
Correct Answer: C
Rationale: Thermoregulation is a critical priority because newborns are highly susceptible
to heat loss through evaporation and convection. Cold stress can lead to increased oxygen
consumption and metabolic acidosis, which complicates the transition to extrauterine life.
While medications and assessments are important, drying the skin and providing skin-to-
skin contact or a radiant warmer must happen first to stabilize the infant.
3. A client is in the first stage of labor and is 6 cm dilated. The nurse notes late decelerations
on the fetal heart rate monitor. What should be the nurse’s first action?
A. Assist the client to a side-lying position
B. Increase the IV oxytocin infusion rate
C. Prepare for an immediate vaginal delivery
D. Perform a sterile vaginal examination
Correct Answer: A
Rationale: Late decelerations are indicative of uteroplacental insufficiency, meaning the
fetus is not receiving adequate oxygen during contractions. Repositioning the mother to
her side (left or right) relieves pressure on the inferior vena cava and improves blood flow
to the placenta. The nurse should also discontinue oxytocin if it is running and provide
supplemental oxygen to maximize fetal oxygenation.
,4. A postpartum client who is breastfeeding complains of nipple soreness. Which
recommendation by the nurse is most appropriate?
A. Ensure the infant’s mouth covers the entire nipple and most of the areola
B. Apply a plastic-backed breast pad to keep the area dry
C. Use soap and water to clean the nipples twice daily
D. Limit breastfeeding to 5 minutes per side until healed
Correct Answer: A
Rationale: Incorrect latch is the most common cause of nipple trauma and soreness in
breastfeeding mothers. A proper latch ensures that the nipple is positioned deep in the
infant’s mouth against the soft palate, preventing friction. The nurse should assess the
breastfeeding technique and encourage the mother to let her nipples air dry after feedings.
5. A nurse is evaluating an infant with suspected pyloric stenosis. Which clinical manifestation
is most characteristic of this condition?
A. Currant jelly-like stools
B. Abdominal distention and bile-stained emesis
C. Projectile vomiting after feedings
D. Steatorrhea and failure to thrive
Correct Answer: C
, Rationale: Projectile vomiting is the hallmark sign of hypertrophic pyloric stenosis due to
the mechanical obstruction of the gastric outlet. This vomiting typically occurs shortly after
feeding and does not contain bile because the obstruction is proximal to the bile duct.
Additionally, a palpable olive-shaped mass may be felt in the right upper quadrant of the
abdomen during physical assessment.
6. What is the primary purpose of administering Magnesium Sulfate to a client with
preeclampsia?
A. To lower the blood pressure to a normal range
B. To stimulate the production of fetal surfactant
C. To increase urinary output and reduce edema
D. To prevent the occurrence of seizures (eclampsia)
Correct Answer: D
Rationale: Magnesium Sulfate is a central nervous system depressant used primarily as an
anticonvulsant in clients with preeclampsia. While it may have a mild vasodilatory effect
that slightly lowers blood pressure, its clinical purpose is to prevent the transition to
eclampsia. Nurses must monitor the client closely for toxicity signs, such as loss of deep
tendon reflexes or respiratory depression.
7. A child is diagnosed with Tetralogy of Fallot and experiences a ‘Tet spell’ during a blood
draw. What is the nurse’s immediate priority?
A. Administer a dose of Digoxin
Maternal-Child Nursing Q&A with
Rationale | Rasmussen University
1. A nurse is assessing a pregnant client at 34 weeks gestation who presents with sudden,
painless vaginal bleeding. Which condition should the nurse suspect?
A. Abruptio placentae
B. Hydatidiform mole
C. Cervical insufficiency
D. Placenta previa
Correct Answer: D
Rationale: Placenta previa is characterized by the sudden onset of painless, bright red
vaginal bleeding in the second or third trimester. Unlike placental abruption, which
involves painful bleeding and uterine rigidity, placenta previa is typically painless because
the placenta is simply covering the internal os. The nurse must avoid performing a vaginal
exam until the placental location is confirmed by ultrasound to prevent hemorrhage.
2. Which of the following interventions is the priority for a nurse caring for a newborn
immediately after birth?
A. Administering Vitamin K intramuscularly
B. Applying erythromycin ophthalmic ointment
,C. Drying the infant and maintaining thermoregulation
D. Performing the initial physical assessment
Correct Answer: C
Rationale: Thermoregulation is a critical priority because newborns are highly susceptible
to heat loss through evaporation and convection. Cold stress can lead to increased oxygen
consumption and metabolic acidosis, which complicates the transition to extrauterine life.
While medications and assessments are important, drying the skin and providing skin-to-
skin contact or a radiant warmer must happen first to stabilize the infant.
3. A client is in the first stage of labor and is 6 cm dilated. The nurse notes late decelerations
on the fetal heart rate monitor. What should be the nurse’s first action?
A. Assist the client to a side-lying position
B. Increase the IV oxytocin infusion rate
C. Prepare for an immediate vaginal delivery
D. Perform a sterile vaginal examination
Correct Answer: A
Rationale: Late decelerations are indicative of uteroplacental insufficiency, meaning the
fetus is not receiving adequate oxygen during contractions. Repositioning the mother to
her side (left or right) relieves pressure on the inferior vena cava and improves blood flow
to the placenta. The nurse should also discontinue oxytocin if it is running and provide
supplemental oxygen to maximize fetal oxygenation.
,4. A postpartum client who is breastfeeding complains of nipple soreness. Which
recommendation by the nurse is most appropriate?
A. Ensure the infant’s mouth covers the entire nipple and most of the areola
B. Apply a plastic-backed breast pad to keep the area dry
C. Use soap and water to clean the nipples twice daily
D. Limit breastfeeding to 5 minutes per side until healed
Correct Answer: A
Rationale: Incorrect latch is the most common cause of nipple trauma and soreness in
breastfeeding mothers. A proper latch ensures that the nipple is positioned deep in the
infant’s mouth against the soft palate, preventing friction. The nurse should assess the
breastfeeding technique and encourage the mother to let her nipples air dry after feedings.
5. A nurse is evaluating an infant with suspected pyloric stenosis. Which clinical manifestation
is most characteristic of this condition?
A. Currant jelly-like stools
B. Abdominal distention and bile-stained emesis
C. Projectile vomiting after feedings
D. Steatorrhea and failure to thrive
Correct Answer: C
, Rationale: Projectile vomiting is the hallmark sign of hypertrophic pyloric stenosis due to
the mechanical obstruction of the gastric outlet. This vomiting typically occurs shortly after
feeding and does not contain bile because the obstruction is proximal to the bile duct.
Additionally, a palpable olive-shaped mass may be felt in the right upper quadrant of the
abdomen during physical assessment.
6. What is the primary purpose of administering Magnesium Sulfate to a client with
preeclampsia?
A. To lower the blood pressure to a normal range
B. To stimulate the production of fetal surfactant
C. To increase urinary output and reduce edema
D. To prevent the occurrence of seizures (eclampsia)
Correct Answer: D
Rationale: Magnesium Sulfate is a central nervous system depressant used primarily as an
anticonvulsant in clients with preeclampsia. While it may have a mild vasodilatory effect
that slightly lowers blood pressure, its clinical purpose is to prevent the transition to
eclampsia. Nurses must monitor the client closely for toxicity signs, such as loss of deep
tendon reflexes or respiratory depression.
7. A child is diagnosed with Tetralogy of Fallot and experiences a ‘Tet spell’ during a blood
draw. What is the nurse’s immediate priority?
A. Administer a dose of Digoxin
