NUR2513/NUR 2513 Exam 4 V3 | Maternal
Child Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is assessing a client who is in the third trimester of pregnancy and reports sudden,
painless bright red vaginal bleeding. Which of the following conditions should the nurse
suspect?
A. Abruptio placentae
B. Hydatidiform mole
C. Uterine rupture
D. Placenta previa
Correct Answer: D
Rationale: Placenta previa is characterized by the painless, bright red bleeding that occurs
in the late second or third trimester. Unlike abruptio placentae, which is typically painful
and associated with uterine tenderness, placenta previa involves the placenta covering the
cervical os. The nurse must avoid performing a vaginal exam until the location of the
placenta is confirmed by ultrasound.
2. A nurse is caring for a client who is receiving magnesium sulfate IV for preeclampsia. Which
of the following findings should the nurse identify as a priority?
A. Urine output of 40 mL/hr
,B. Blood pressure of 150/96 mm Hg
C. Deep tendon reflexes of 2+
D. Respiratory rate of 10/min
Correct Answer: D
Rationale: A respiratory rate of 10/min is below the normal range and is a sign of
magnesium sulfate toxicity. The therapeutic range for magnesium sulfate requires
monitoring for respiratory depression and loss of deep tendon reflexes. The nurse should
immediately discontinue the infusion and notify the provider if toxic signs appear.
3. Which of the following nursing interventions is appropriate for a child who has been
diagnosed with acute epiglottitis?
A. Obtaining a throat culture
B. Maintaining a tripod position for the child
C. Encouraging oral fluids to thin secretions
D. Visualizing the airway with a tongue depressor
Correct Answer: B
Rationale: Children with epiglottitis often instinctively assume a tripod position to help
maintain an open airway. It is critical to avoid any throat manipulation, such as cultures or
tongue depressors, as this can trigger a laryngospasm and complete airway obstruction.
, The nurse should keep the child calm and have emergency intubation equipment available
at the bedside.
4. A nurse is assessing a 4-hour-old newborn for signs of respiratory distress. Which of the
following findings should the nurse report to the provider?
A. Nasal flaring
B. Irregular respirations
C. Respiratory rate of 50/min
D. Acrocyanosis
Correct Answer: A
Rationale: Nasal flaring is a classic sign of respiratory distress in a newborn and indicates
the infant is working harder to breathe. While irregular respirations and acrocyanosis
(blue extremities) can be normal in the first few hours of life, flaring requires immediate
investigation. Other signs of distress include grunting and intercostal retractions.
5. A nurse is providing teaching to a client about the use of a diaphragm for contraception.
Which of the following instructions should the nurse include?
A. The device should be replaced every 5 years.
B. Remove the diaphragm immediately after intercourse.
C. Apply spermicide to the rim of the diaphragm before insertion.
D. Use oil-based lubricants to assist with insertion.
Child Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is assessing a client who is in the third trimester of pregnancy and reports sudden,
painless bright red vaginal bleeding. Which of the following conditions should the nurse
suspect?
A. Abruptio placentae
B. Hydatidiform mole
C. Uterine rupture
D. Placenta previa
Correct Answer: D
Rationale: Placenta previa is characterized by the painless, bright red bleeding that occurs
in the late second or third trimester. Unlike abruptio placentae, which is typically painful
and associated with uterine tenderness, placenta previa involves the placenta covering the
cervical os. The nurse must avoid performing a vaginal exam until the location of the
placenta is confirmed by ultrasound.
2. A nurse is caring for a client who is receiving magnesium sulfate IV for preeclampsia. Which
of the following findings should the nurse identify as a priority?
A. Urine output of 40 mL/hr
,B. Blood pressure of 150/96 mm Hg
C. Deep tendon reflexes of 2+
D. Respiratory rate of 10/min
Correct Answer: D
Rationale: A respiratory rate of 10/min is below the normal range and is a sign of
magnesium sulfate toxicity. The therapeutic range for magnesium sulfate requires
monitoring for respiratory depression and loss of deep tendon reflexes. The nurse should
immediately discontinue the infusion and notify the provider if toxic signs appear.
3. Which of the following nursing interventions is appropriate for a child who has been
diagnosed with acute epiglottitis?
A. Obtaining a throat culture
B. Maintaining a tripod position for the child
C. Encouraging oral fluids to thin secretions
D. Visualizing the airway with a tongue depressor
Correct Answer: B
Rationale: Children with epiglottitis often instinctively assume a tripod position to help
maintain an open airway. It is critical to avoid any throat manipulation, such as cultures or
tongue depressors, as this can trigger a laryngospasm and complete airway obstruction.
, The nurse should keep the child calm and have emergency intubation equipment available
at the bedside.
4. A nurse is assessing a 4-hour-old newborn for signs of respiratory distress. Which of the
following findings should the nurse report to the provider?
A. Nasal flaring
B. Irregular respirations
C. Respiratory rate of 50/min
D. Acrocyanosis
Correct Answer: A
Rationale: Nasal flaring is a classic sign of respiratory distress in a newborn and indicates
the infant is working harder to breathe. While irregular respirations and acrocyanosis
(blue extremities) can be normal in the first few hours of life, flaring requires immediate
investigation. Other signs of distress include grunting and intercostal retractions.
5. A nurse is providing teaching to a client about the use of a diaphragm for contraception.
Which of the following instructions should the nurse include?
A. The device should be replaced every 5 years.
B. Remove the diaphragm immediately after intercourse.
C. Apply spermicide to the rim of the diaphragm before insertion.
D. Use oil-based lubricants to assist with insertion.
