NUR2513/NUR 2513 Exam 3 V3 | Maternal-
Child Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is monitoring a client in labor and notices late decelerations on the fetal monitor.
Which action should the nurse take first?
A. Apply oxygen at 8 to 10 L/min via a nonrebreather mask.
B. Place the client in a supine position.
C. Increase the rate of the oxytocin infusion.
D. Perform a vaginal exam to check for cord prolapse.
Correct Answer: A
Rationale: Late decelerations are indicative of uteroplacental insufficiency and require
immediate intervention to improve fetal oxygenation. The nurse should also turn the client
to a side-lying position and discontinue oxytocin if it is being administered. These actions
aim to increase blood flow and oxygen delivery to the fetus.
2. A nurse is assessing a client who is 2 hours postpartum and has a boggy fundus that is
displaced to the right. Which of the following is the priority nursing action?
A. Administer oxytocin as prescribed.
B. Notify the healthcare provider immediately.
C. Perform vigorous fundal massage.
,D. Assist the client to empty their bladder.
Correct Answer: D
Rationale: A displaced fundus, especially to the right, usually indicates a full bladder that is
preventing the uterus from contracting effectively. Assisting the client to void allows the
uterus to return to the midline and contract to prevent hemorrhage. If the fundus remains
boggy after voiding, massage and medications would be the next steps.
3. A client at 32 weeks gestation is receiving magnesium sulfate for preeclampsia. Which
assessment finding should the nurse report to the provider immediately?
A. Blood pressure of 150/96 mmHg.
B. Deep tendon reflexes of 2+.
C. Respirations of 10 breaths per minute.
D. Urinary output of 40 mL/hour.
Correct Answer: C
Rationale: A respiratory rate below 12 per minute is a sign of magnesium sulfate toxicity
and requires immediate intervention. The nurse should stop the infusion and prepare to
administer calcium gluconate, the antidote. Other signs of toxicity include absent deep
tendon reflexes and significantly decreased urinary output.
4. The nurse is caring for a newborn immediately after birth. Which of the following is the
highest priority for the nurse to perform?
A. Administer the Vitamin K injection.
, B. Dry the newborn and provide a warm environment.
C. Apply erythromycin ophthalmic ointment.
D. Obtain the newborn’s weight and length.
Correct Answer: B
Rationale: Newborns are at high risk for cold stress due to their large surface area and
limited ability to generate heat. Drying the infant and using radiant warmers or skin-to-
skin contact is the priority to prevent respiratory distress and metabolic acidosis.
Medications and measurements can be delayed until the infant is stable and warm.
5. A nurse is providing discharge teaching to a client who is breastfeeding. Which statement
by the client indicates a need for further instruction?
A. ‘I should feed my baby every 2 to 3 hours or on demand.’
B. ‘I will know my baby is getting enough milk if they have 6 to 8 wet diapers a day.’
C. ‘I should use soap on my nipples to keep them clean and prevent infection.’
D. ‘I will alternate which breast I start with at each feeding.’
Correct Answer: C
Rationale: Soap can be drying and lead to cracked or irritated nipples, which increases the
risk of infection. Clients should use only plain water to clean the breasts and can apply
expressed breast milk to the nipples for healing. Proper latching technique is the best way
to prevent nipple soreness.
Child Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is monitoring a client in labor and notices late decelerations on the fetal monitor.
Which action should the nurse take first?
A. Apply oxygen at 8 to 10 L/min via a nonrebreather mask.
B. Place the client in a supine position.
C. Increase the rate of the oxytocin infusion.
D. Perform a vaginal exam to check for cord prolapse.
Correct Answer: A
Rationale: Late decelerations are indicative of uteroplacental insufficiency and require
immediate intervention to improve fetal oxygenation. The nurse should also turn the client
to a side-lying position and discontinue oxytocin if it is being administered. These actions
aim to increase blood flow and oxygen delivery to the fetus.
2. A nurse is assessing a client who is 2 hours postpartum and has a boggy fundus that is
displaced to the right. Which of the following is the priority nursing action?
A. Administer oxytocin as prescribed.
B. Notify the healthcare provider immediately.
C. Perform vigorous fundal massage.
,D. Assist the client to empty their bladder.
Correct Answer: D
Rationale: A displaced fundus, especially to the right, usually indicates a full bladder that is
preventing the uterus from contracting effectively. Assisting the client to void allows the
uterus to return to the midline and contract to prevent hemorrhage. If the fundus remains
boggy after voiding, massage and medications would be the next steps.
3. A client at 32 weeks gestation is receiving magnesium sulfate for preeclampsia. Which
assessment finding should the nurse report to the provider immediately?
A. Blood pressure of 150/96 mmHg.
B. Deep tendon reflexes of 2+.
C. Respirations of 10 breaths per minute.
D. Urinary output of 40 mL/hour.
Correct Answer: C
Rationale: A respiratory rate below 12 per minute is a sign of magnesium sulfate toxicity
and requires immediate intervention. The nurse should stop the infusion and prepare to
administer calcium gluconate, the antidote. Other signs of toxicity include absent deep
tendon reflexes and significantly decreased urinary output.
4. The nurse is caring for a newborn immediately after birth. Which of the following is the
highest priority for the nurse to perform?
A. Administer the Vitamin K injection.
, B. Dry the newborn and provide a warm environment.
C. Apply erythromycin ophthalmic ointment.
D. Obtain the newborn’s weight and length.
Correct Answer: B
Rationale: Newborns are at high risk for cold stress due to their large surface area and
limited ability to generate heat. Drying the infant and using radiant warmers or skin-to-
skin contact is the priority to prevent respiratory distress and metabolic acidosis.
Medications and measurements can be delayed until the infant is stable and warm.
5. A nurse is providing discharge teaching to a client who is breastfeeding. Which statement
by the client indicates a need for further instruction?
A. ‘I should feed my baby every 2 to 3 hours or on demand.’
B. ‘I will know my baby is getting enough milk if they have 6 to 8 wet diapers a day.’
C. ‘I should use soap on my nipples to keep them clean and prevent infection.’
D. ‘I will alternate which breast I start with at each feeding.’
Correct Answer: C
Rationale: Soap can be drying and lead to cracked or irritated nipples, which increases the
risk of infection. Clients should use only plain water to clean the breasts and can apply
expressed breast milk to the nipples for healing. Proper latching technique is the best way
to prevent nipple soreness.
