NUR2513/NUR 2513 Exam 3 V2 | Maternal
Child Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is monitoring a fetal heart rate (FHR) tracing and notes early decelerations. Which
of the following is the most appropriate nursing action?
A. Administer oxygen via non-rebreather mask at 10 L/min.
B. Prepare the patient for an emergency cesarean section.
C. Continue to monitor the patient as this is a benign finding.
D. Increase the rate of the intravenous maintenance fluids.
Correct Answer: C
Rationale: Early decelerations are typically caused by fetal head compression during
contractions. They are considered a reassuring or benign finding and do not indicate fetal
distress. The nurse should continue to observe the labor progress and document the
findings.
2. A client in the second stage of labor is experiencing a shoulder dystocia. Which
intervention should the nurse implement first?
A. Perform the McRoberts maneuver by flexing the mother’s thighs.
B. Apply fundal pressure to assist with the delivery of the fetus.
C. Prepare for immediate administration of general anesthesia.
,D. Assess the fetal heart rate for signs of late decelerations.
Correct Answer: A
Rationale: The McRoberts maneuver is the primary nursing intervention to resolve
shoulder dystocia by opening the pelvic outlet. Fundal pressure is strictly contraindicated
as it can further wedge the shoulder behind the symphysis pubis. Prompt action is
necessary to prevent fetal hypoxia and brachial plexus injury.
3. A postpartum nurse is assessing a client 2 hours after delivery and notes a boggy uterus
that is displaced to the right. What is the priority nursing action?
A. Administer PRN oxytocin as ordered by the provider.
B. Perform vigorous fundal massage immediately.
C. Assist the client to the bathroom to void.
D. Notify the healthcare provider of a potential hemorrhage.
Correct Answer: C
Rationale: A uterus that is boggy and displaced to the right is a classic sign of bladder
distention. A full bladder prevents the uterus from contracting effectively, increasing the
risk of postpartum hemorrhage. Assisting the patient to void will allow the uterus to return
to the midline and firm up.
,4. The nurse is evaluating an APGAR score for a newborn at 1 minute. The heart rate is 110,
there is a weak cry, some flexion of extremities, the baby grimaces when suctioned, and the
body is pink with blue extremities. What is the score?
A. 5
B. 6
C. 7
D. 8
Correct Answer: B
Rationale: The score is calculated as follows: Heart rate >100 (2), Weak cry (1), Some
flexion (1), Grimace (1), and Acrocyanosis (1). This totals a score of 6, which indicates the
infant may require some resuscitation or stimulation. APGAR scoring is performed at 1 and
5 minutes to assess the newborn’s transition to extrauterine life.
5. A client with preeclampsia is receiving Magnesium Sulfate. The nurse notes a respiratory
rate of 10 breaths/min and absent deep tendon reflexes. Which medication should be readily
available?
A. Naloxone
B. Terbutaline
C. Hydralazine
D. Calcium Gluconate
, Correct Answer: D
Rationale: Calcium gluconate is the specific antidote for magnesium sulfate toxicity. Signs
of toxicity include bradypnea, loss of deep tendon reflexes, and decreased urinary output.
The nurse must stop the magnesium infusion immediately before administering the
antidote.
6. Which of the following is a characteristic of the ‘Taking-In’ phase of postpartum
psychological adaptation?
A. The mother focuses on her own needs for sleep and nutrition.
B. The mother is eager to learn about newborn care techniques.
C. The mother assumes full responsibility for the infant’s well-being.
D. The mother begins to view the infant as a separate individual.
Correct Answer: A
Rationale: During the ‘Taking-In’ phase, which occurs in the first 24-48 hours, the mother
is often passive and dependent. She focuses on her own recovery and frequently recounts
her labor experience to integrate it. This phase precedes the ‘Taking-Hold’ phase where she
becomes more active in infant care.
7. A newborn is diagnosed with hyperbilirubinemia and is placed under phototherapy. Which
nursing intervention is essential?
A. Apply lotion to the baby’s skin to prevent drying.
B. Limit fluid intake to prevent overhydration.
Child Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is monitoring a fetal heart rate (FHR) tracing and notes early decelerations. Which
of the following is the most appropriate nursing action?
A. Administer oxygen via non-rebreather mask at 10 L/min.
B. Prepare the patient for an emergency cesarean section.
C. Continue to monitor the patient as this is a benign finding.
D. Increase the rate of the intravenous maintenance fluids.
Correct Answer: C
Rationale: Early decelerations are typically caused by fetal head compression during
contractions. They are considered a reassuring or benign finding and do not indicate fetal
distress. The nurse should continue to observe the labor progress and document the
findings.
2. A client in the second stage of labor is experiencing a shoulder dystocia. Which
intervention should the nurse implement first?
A. Perform the McRoberts maneuver by flexing the mother’s thighs.
B. Apply fundal pressure to assist with the delivery of the fetus.
C. Prepare for immediate administration of general anesthesia.
,D. Assess the fetal heart rate for signs of late decelerations.
Correct Answer: A
Rationale: The McRoberts maneuver is the primary nursing intervention to resolve
shoulder dystocia by opening the pelvic outlet. Fundal pressure is strictly contraindicated
as it can further wedge the shoulder behind the symphysis pubis. Prompt action is
necessary to prevent fetal hypoxia and brachial plexus injury.
3. A postpartum nurse is assessing a client 2 hours after delivery and notes a boggy uterus
that is displaced to the right. What is the priority nursing action?
A. Administer PRN oxytocin as ordered by the provider.
B. Perform vigorous fundal massage immediately.
C. Assist the client to the bathroom to void.
D. Notify the healthcare provider of a potential hemorrhage.
Correct Answer: C
Rationale: A uterus that is boggy and displaced to the right is a classic sign of bladder
distention. A full bladder prevents the uterus from contracting effectively, increasing the
risk of postpartum hemorrhage. Assisting the patient to void will allow the uterus to return
to the midline and firm up.
,4. The nurse is evaluating an APGAR score for a newborn at 1 minute. The heart rate is 110,
there is a weak cry, some flexion of extremities, the baby grimaces when suctioned, and the
body is pink with blue extremities. What is the score?
A. 5
B. 6
C. 7
D. 8
Correct Answer: B
Rationale: The score is calculated as follows: Heart rate >100 (2), Weak cry (1), Some
flexion (1), Grimace (1), and Acrocyanosis (1). This totals a score of 6, which indicates the
infant may require some resuscitation or stimulation. APGAR scoring is performed at 1 and
5 minutes to assess the newborn’s transition to extrauterine life.
5. A client with preeclampsia is receiving Magnesium Sulfate. The nurse notes a respiratory
rate of 10 breaths/min and absent deep tendon reflexes. Which medication should be readily
available?
A. Naloxone
B. Terbutaline
C. Hydralazine
D. Calcium Gluconate
, Correct Answer: D
Rationale: Calcium gluconate is the specific antidote for magnesium sulfate toxicity. Signs
of toxicity include bradypnea, loss of deep tendon reflexes, and decreased urinary output.
The nurse must stop the magnesium infusion immediately before administering the
antidote.
6. Which of the following is a characteristic of the ‘Taking-In’ phase of postpartum
psychological adaptation?
A. The mother focuses on her own needs for sleep and nutrition.
B. The mother is eager to learn about newborn care techniques.
C. The mother assumes full responsibility for the infant’s well-being.
D. The mother begins to view the infant as a separate individual.
Correct Answer: A
Rationale: During the ‘Taking-In’ phase, which occurs in the first 24-48 hours, the mother
is often passive and dependent. She focuses on her own recovery and frequently recounts
her labor experience to integrate it. This phase precedes the ‘Taking-Hold’ phase where she
becomes more active in infant care.
7. A newborn is diagnosed with hyperbilirubinemia and is placed under phototherapy. Which
nursing intervention is essential?
A. Apply lotion to the baby’s skin to prevent drying.
B. Limit fluid intake to prevent overhydration.
