NUR2513/NUR 2513 Exam 3 V3 | Maternal
Child Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is monitoring a client who is receiving magnesium sulfate via continuous IV
infusion for preeclampsia. Which of the following findings should the nurse report to the
provider immediately?
A. Urine output of 20 mL/hr
B. Deep tendon reflexes of 2+
C. Respiratory rate of 14/min
D. Blood pressure of 150/95 mmHg
Correct Answer: A
Rationale: Magnesium sulfate is excreted by the kidneys, and a decrease in urine output
below 30 mL/hr can lead to magnesium toxicity. The nurse must monitor for signs of
toxicity such as respiratory depression and absent deep tendon reflexes. Monitoring renal
function is vital to ensure the client is safely clearing the medication.
2. A nurse is caring for a client in the transition phase of the first stage of labor. Which of the
following manifestations should the nurse expect?
A. Dilation of 1 to 3 cm
B. The client being talkative and excited
,C. Contractions occurring every 10 to 15 minutes
D. Frequent urge to push or have a bowel movement
Correct Answer: D
Rationale: The transition phase occurs when the cervix is dilated 8 to 10 cm, often
resulting in an intense urge to push. Clients in this phase often experience irritability,
nausea, and a feeling of loss of control. This is the final and most intense part of the first
stage of labor.
3. The nurse observes a fetal heart rate (FHR) pattern showing variable decelerations on the
monitor. Which of the following actions should the nurse take first?
A. Increase the IV fluid rate
B. Administer oxygen via nonrebreather mask
C. Perform a vaginal exam
D. Assist the client into a side-lying or knee-chest position
Correct Answer: D
Rationale: Variable decelerations are typically caused by umbilical cord compression
during contractions or fetal movement. Changing the maternal position is the priority
action to relieve pressure on the cord and improve fetal oxygenation. The nurse should also
assess for cord prolapse if position changes do not resolve the issue.
, 4. A nurse is providing discharge teaching to a parent of a newborn regarding the Moro reflex.
Which of the following descriptions should the nurse include?
A. The newborn turns the head toward the side where the cheek is touched.
B. The newborn makes stepping movements when held upright with feet touching a
surface.
C. The newborn curls the toes downward when the sole of the foot is touched.
D. The newborn’s arms and legs extend and then abduct in response to a loud noise.
Correct Answer: D
Rationale: The Moro reflex, also known as the startle reflex, is an expected finding in
newborns until about 4 months of age. It is elicited by a sudden change in position or a loud
noise, causing the infant to extend the limbs. Asymmetric response may indicate injury to
the brachial plexus or a fractured clavicle.
5. A nurse is assessing a client who is 2 hours postpartum. The nurse notes the fundus is
boggy and displaced to the right. Which of the following actions should the nurse take?
A. Administer oxytocin IV bolus
B. Notify the provider of potential hemorrhage
C. Massage the fundus until firm
D. Assist the client to the bathroom to void
Correct Answer: D
Child Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is monitoring a client who is receiving magnesium sulfate via continuous IV
infusion for preeclampsia. Which of the following findings should the nurse report to the
provider immediately?
A. Urine output of 20 mL/hr
B. Deep tendon reflexes of 2+
C. Respiratory rate of 14/min
D. Blood pressure of 150/95 mmHg
Correct Answer: A
Rationale: Magnesium sulfate is excreted by the kidneys, and a decrease in urine output
below 30 mL/hr can lead to magnesium toxicity. The nurse must monitor for signs of
toxicity such as respiratory depression and absent deep tendon reflexes. Monitoring renal
function is vital to ensure the client is safely clearing the medication.
2. A nurse is caring for a client in the transition phase of the first stage of labor. Which of the
following manifestations should the nurse expect?
A. Dilation of 1 to 3 cm
B. The client being talkative and excited
,C. Contractions occurring every 10 to 15 minutes
D. Frequent urge to push or have a bowel movement
Correct Answer: D
Rationale: The transition phase occurs when the cervix is dilated 8 to 10 cm, often
resulting in an intense urge to push. Clients in this phase often experience irritability,
nausea, and a feeling of loss of control. This is the final and most intense part of the first
stage of labor.
3. The nurse observes a fetal heart rate (FHR) pattern showing variable decelerations on the
monitor. Which of the following actions should the nurse take first?
A. Increase the IV fluid rate
B. Administer oxygen via nonrebreather mask
C. Perform a vaginal exam
D. Assist the client into a side-lying or knee-chest position
Correct Answer: D
Rationale: Variable decelerations are typically caused by umbilical cord compression
during contractions or fetal movement. Changing the maternal position is the priority
action to relieve pressure on the cord and improve fetal oxygenation. The nurse should also
assess for cord prolapse if position changes do not resolve the issue.
, 4. A nurse is providing discharge teaching to a parent of a newborn regarding the Moro reflex.
Which of the following descriptions should the nurse include?
A. The newborn turns the head toward the side where the cheek is touched.
B. The newborn makes stepping movements when held upright with feet touching a
surface.
C. The newborn curls the toes downward when the sole of the foot is touched.
D. The newborn’s arms and legs extend and then abduct in response to a loud noise.
Correct Answer: D
Rationale: The Moro reflex, also known as the startle reflex, is an expected finding in
newborns until about 4 months of age. It is elicited by a sudden change in position or a loud
noise, causing the infant to extend the limbs. Asymmetric response may indicate injury to
the brachial plexus or a fractured clavicle.
5. A nurse is assessing a client who is 2 hours postpartum. The nurse notes the fundus is
boggy and displaced to the right. Which of the following actions should the nurse take?
A. Administer oxytocin IV bolus
B. Notify the provider of potential hemorrhage
C. Massage the fundus until firm
D. Assist the client to the bathroom to void
Correct Answer: D
