NUR2513/NUR 2513 Exam 4 V1 | Maternal-
Child Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is assessing a client who is 2 hours postpartum and identifies that the fundus is
boggy and displaced to the right. Which of the following actions should the nurse take first?
A. Administer oxytocin via intravenous infusion.
B. Assist the client to the bathroom to void.
C. Perform vigorous fundal massage.
D. Notify the provider of the findings.
Correct Answer: B
Rationale: A fundus that is displaced to the right is a classic sign of bladder distention. A
full bladder prevents the uterus from contracting efficiently, which can lead to uterine
atony and hemorrhage. Emptying the bladder is the priority intervention to allow the
uterus to return to the midline and contract.
2. A nurse is monitoring a client who is receiving magnesium sulfate for pre-eclampsia. Which
of the following findings should the nurse report to the provider as a sign of toxicity?
A. Blood pressure of 150/90 mmHg.
B. Urine output of 40 mL per hour.
C. Deep tendon reflexes of 2+.
,D. Respiratory rate of 10 breaths per minute.
Correct Answer: D
Rationale: Magnesium sulfate is a central nervous system depressant used to prevent
seizures. A respiratory rate of less than 12 per minute is a major indicator of magnesium
toxicity. The nurse must immediately stop the infusion and notify the physician if this
occurs.
3. A newborn is being treated with phototherapy for hyperbilirubinemia. Which of the
following nursing interventions is essential for this infant’s care?
A. Applying lotion to the infant’s skin.
B. Limiting fluid intake to prevent diarrhea.
C. Ensuring the eyes and genitalia are covered.
D. Keeping the infant in a prone position exclusively.
Correct Answer: C
Rationale: Phototherapy uses light to break down bilirubin, but the light can damage the
infant’s retina. Covering the eyes with an opaque mask and the genitalia with a small diaper
is necessary to prevent injury. Additionally, the nurse should monitor for dehydration as
phototherapy can increase insensible water loss.
4. A nurse is providing discharge teaching to the parents of a child with cystic fibrosis. Which
of the following instructions should be included regarding pancreatic enzyme administration?
A. Administer enzymes once daily in the morning.
, B. Skip the dose if the child has a large bowel movement.
C. Give enzymes with every meal and snack.
D. Crush the enzymes and mix them with warm milk.
Correct Answer: C
Rationale: Children with cystic fibrosis have pancreatic insufficiency and cannot digest fats
or proteins properly. Pancreatic enzymes must be taken with every meal and snack to
facilitate nutrient absorption. The effectiveness of the therapy is monitored by evaluating
the consistency and frequency of stools.
5. A school-age child is admitted to the hospital in a vaso-occlusive sickle cell crisis. Which of
the following is the priority nursing intervention?
A. Applying cold compresses to painful joints.
B. Administering meperidine for pain management.
C. Increasing intravenous and oral fluid intake.
D. Restricting physical activity to promote rest.
Correct Answer: C
Rationale: Hydration is the priority in a sickle cell crisis because it helps reduce blood
viscosity and prevents further sickling of red blood cells. Increasing fluids promotes the
movement of sickled cells through the vasculature. Pain management with scheduled
Child Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is assessing a client who is 2 hours postpartum and identifies that the fundus is
boggy and displaced to the right. Which of the following actions should the nurse take first?
A. Administer oxytocin via intravenous infusion.
B. Assist the client to the bathroom to void.
C. Perform vigorous fundal massage.
D. Notify the provider of the findings.
Correct Answer: B
Rationale: A fundus that is displaced to the right is a classic sign of bladder distention. A
full bladder prevents the uterus from contracting efficiently, which can lead to uterine
atony and hemorrhage. Emptying the bladder is the priority intervention to allow the
uterus to return to the midline and contract.
2. A nurse is monitoring a client who is receiving magnesium sulfate for pre-eclampsia. Which
of the following findings should the nurse report to the provider as a sign of toxicity?
A. Blood pressure of 150/90 mmHg.
B. Urine output of 40 mL per hour.
C. Deep tendon reflexes of 2+.
,D. Respiratory rate of 10 breaths per minute.
Correct Answer: D
Rationale: Magnesium sulfate is a central nervous system depressant used to prevent
seizures. A respiratory rate of less than 12 per minute is a major indicator of magnesium
toxicity. The nurse must immediately stop the infusion and notify the physician if this
occurs.
3. A newborn is being treated with phototherapy for hyperbilirubinemia. Which of the
following nursing interventions is essential for this infant’s care?
A. Applying lotion to the infant’s skin.
B. Limiting fluid intake to prevent diarrhea.
C. Ensuring the eyes and genitalia are covered.
D. Keeping the infant in a prone position exclusively.
Correct Answer: C
Rationale: Phototherapy uses light to break down bilirubin, but the light can damage the
infant’s retina. Covering the eyes with an opaque mask and the genitalia with a small diaper
is necessary to prevent injury. Additionally, the nurse should monitor for dehydration as
phototherapy can increase insensible water loss.
4. A nurse is providing discharge teaching to the parents of a child with cystic fibrosis. Which
of the following instructions should be included regarding pancreatic enzyme administration?
A. Administer enzymes once daily in the morning.
, B. Skip the dose if the child has a large bowel movement.
C. Give enzymes with every meal and snack.
D. Crush the enzymes and mix them with warm milk.
Correct Answer: C
Rationale: Children with cystic fibrosis have pancreatic insufficiency and cannot digest fats
or proteins properly. Pancreatic enzymes must be taken with every meal and snack to
facilitate nutrient absorption. The effectiveness of the therapy is monitored by evaluating
the consistency and frequency of stools.
5. A school-age child is admitted to the hospital in a vaso-occlusive sickle cell crisis. Which of
the following is the priority nursing intervention?
A. Applying cold compresses to painful joints.
B. Administering meperidine for pain management.
C. Increasing intravenous and oral fluid intake.
D. Restricting physical activity to promote rest.
Correct Answer: C
Rationale: Hydration is the priority in a sickle cell crisis because it helps reduce blood
viscosity and prevents further sickling of red blood cells. Increasing fluids promotes the
movement of sickled cells through the vasculature. Pain management with scheduled
