NUR2513/NUR 2513 Exam 3 V1 | Maternal-
Child Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is caring for a client in the first stage of labor and notes that the fetal heart rate
(FHR) monitor shows late decelerations. Which of the following is the priority nursing action?
A. Administer oxygen via a non-rebreather mask at 8-10 L/min.
B. Increase the rate of the maintenance intravenous (IV) fluids.
C. Reposition the client to a side-lying position.
D. Prepare the client for an emergency cesarean section.
Correct Answer: C
Rationale: Late decelerations are indicative of uteroplacental insufficiency and require
immediate nursing intervention to improve fetal oxygenation. The first action in the
intrauterine resuscitation sequence is to reposition the client to the lateral position to
relieve pressure on the inferior vena cava and improve blood flow. Other actions like
oxygen administration and increasing IV fluids follow after repositioning has been initiated.
2. A postpartum client is receiving magnesium sulfate for the management of preeclampsia.
Which of the following assessment findings should the nurse report to the provider
immediately?
A. Deep tendon reflexes of +2.
,B. A respiratory rate of 10 breaths per minute.
C. Urine output of 40 mL per hour.
D. A feeling of warmth and flushing.
Correct Answer: B
Rationale: Magnesium sulfate is a central nervous system depressant used to prevent
seizures in preeclamptic patients. A respiratory rate below 12 breaths per minute is a sign
of magnesium toxicity and requires immediate cessation of the infusion and notification of
the provider. The nurse must also monitor for absent deep tendon reflexes and decreased
urinary output as signs of toxicity.
3. A nurse is assessing a newborn 1 minute after birth. The newborn has a heart rate of
110/min, a weak cry, some flexion of the extremities, grimacing when stimulated, 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 APGAR score is calculated based on five criteria. The heart rate over 100
counts for 2 points, the weak cry (respiratory effort) for 1 point, some flexion (muscle
, tone) for 1 point, grimace (reflex irritability) for 1 point, and acrocyanosis (color) for 1
point. Adding these results in a total score of 6, which indicates the infant requires some
assistance.
4. A nurse is providing discharge teaching to a mother who is breastfeeding her newborn.
Which of the following instructions should be included to prevent nipple soreness?
A. Apply soap to the nipples during daily showers.
B. Use a nipple shield for every feeding session.
C. Limit each feeding to 5 minutes per side.
D. Ensure the infant latches onto the nipple and the areola.
Correct Answer: D
Rationale: Proper latch-on is the most effective way to prevent nipple trauma and
soreness during breastfeeding. The infant should take a large portion of the areola into the
mouth, not just the nipple. Soaps should be avoided because they dry out the skin, and
feedings should not be timed but rather based on the infant’s cues.
5. A nurse is evaluating a client at 34 weeks of gestation who is experiencing preterm labor.
Which medication should the nurse anticipate administering to promote fetal lung maturity?
A. Terbutaline
B. Indomethacin
C. Magnesium Sulfate
Child Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is caring for a client in the first stage of labor and notes that the fetal heart rate
(FHR) monitor shows late decelerations. Which of the following is the priority nursing action?
A. Administer oxygen via a non-rebreather mask at 8-10 L/min.
B. Increase the rate of the maintenance intravenous (IV) fluids.
C. Reposition the client to a side-lying position.
D. Prepare the client for an emergency cesarean section.
Correct Answer: C
Rationale: Late decelerations are indicative of uteroplacental insufficiency and require
immediate nursing intervention to improve fetal oxygenation. The first action in the
intrauterine resuscitation sequence is to reposition the client to the lateral position to
relieve pressure on the inferior vena cava and improve blood flow. Other actions like
oxygen administration and increasing IV fluids follow after repositioning has been initiated.
2. A postpartum client is receiving magnesium sulfate for the management of preeclampsia.
Which of the following assessment findings should the nurse report to the provider
immediately?
A. Deep tendon reflexes of +2.
,B. A respiratory rate of 10 breaths per minute.
C. Urine output of 40 mL per hour.
D. A feeling of warmth and flushing.
Correct Answer: B
Rationale: Magnesium sulfate is a central nervous system depressant used to prevent
seizures in preeclamptic patients. A respiratory rate below 12 breaths per minute is a sign
of magnesium toxicity and requires immediate cessation of the infusion and notification of
the provider. The nurse must also monitor for absent deep tendon reflexes and decreased
urinary output as signs of toxicity.
3. A nurse is assessing a newborn 1 minute after birth. The newborn has a heart rate of
110/min, a weak cry, some flexion of the extremities, grimacing when stimulated, 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 APGAR score is calculated based on five criteria. The heart rate over 100
counts for 2 points, the weak cry (respiratory effort) for 1 point, some flexion (muscle
, tone) for 1 point, grimace (reflex irritability) for 1 point, and acrocyanosis (color) for 1
point. Adding these results in a total score of 6, which indicates the infant requires some
assistance.
4. A nurse is providing discharge teaching to a mother who is breastfeeding her newborn.
Which of the following instructions should be included to prevent nipple soreness?
A. Apply soap to the nipples during daily showers.
B. Use a nipple shield for every feeding session.
C. Limit each feeding to 5 minutes per side.
D. Ensure the infant latches onto the nipple and the areola.
Correct Answer: D
Rationale: Proper latch-on is the most effective way to prevent nipple trauma and
soreness during breastfeeding. The infant should take a large portion of the areola into the
mouth, not just the nipple. Soaps should be avoided because they dry out the skin, and
feedings should not be timed but rather based on the infant’s cues.
5. A nurse is evaluating a client at 34 weeks of gestation who is experiencing preterm labor.
Which medication should the nurse anticipate administering to promote fetal lung maturity?
A. Terbutaline
B. Indomethacin
C. Magnesium Sulfate
