NUR2513/NUR 2513 Exam 3 V2 | Maternal-
Child Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is caring for a client at 34 weeks gestation who presents with sudden, severe
abdominal pain and a rigid, board-like abdomen. Which condition should the nurse suspect?
A. Placenta previa
B. Cervical insufficiency
C. Uterine atony
D. Abruptio placentae
Correct Answer: D
Rationale: Abruptio placentae is characterized by the premature separation of the
placenta from the uterine wall, which causes intense pain and uterine rigidity. Unlike
placenta previa, which presents with painless bright red bleeding, abruption often involves
concealed or dark red bleeding. This is a medical emergency requiring immediate
assessment of maternal stability and fetal well-being.
2. A client receiving Magnesium Sulfate for preeclampsia has a respiratory rate of 10/min and
absent deep tendon reflexes (DTRs). What is the priority nursing action?
A. Increase the infusion rate to stabilize blood pressure
B. Encourage the client to use an incentive spirometer
,C. Administer oxygen via nasal cannula at 2L/min
D. Notify the provider and prepare Calcium Gluconate
Correct Answer: D
Rationale: Magnesium toxicity is indicated by a respiratory rate below 12/min, loss of
deep tendon reflexes, and decreased urinary output. The nurse must immediately stop the
infusion to prevent further toxicity. Calcium gluconate is the pharmacological antagonist
that must be kept at the bedside for such emergencies.
3. Which clinical finding is the most reliable indicator of postpartum hemorrhage in a client
who just delivered a 9lb infant?
A. Increased heart rate and decreased blood pressure
B. Saturation of one perineal pad in 15 minutes
C. A boggy uterus that does not firm with massage
D. A temperature of 100.4 F (38 C) in the first 24 hours
Correct Answer: B
Rationale: The saturation of a perineal pad in 15 minutes or less is a critical indicator of
excessive bleeding. Vital sign changes like tachycardia and hypotension are late signs of
hemorrhage due to the increased blood volume of pregnancy. Uterine atony is the most
common cause, and the nurse must prioritize assessing blood loss volume alongside fundal
tone.
, 4. A nurse is assessing a newborn with suspected Tetralogy of Fallot. Which finding is
characteristic of a ‘Tet spell’?
A. Bounding peripheral pulses in all extremities
B. Profound cyanosis during crying or feeding
C. Wheezing and rales upon lung auscultation
D. Bradycardia and increased intracranial pressure
Correct Answer: B
Rationale: Tetralogy of Fallot involves four heart defects that cause oxygen-poor blood to
flow out of the heart and into the body. A ‘Tet spell’ is a hypercyanotic episode triggered by
activities like crying or feeding that increase oxygen demand. Placing the infant in a knee-
chest position helps increase systemic vascular resistance and improve pulmonary blood
flow during these spells.
5. A pediatric client is admitted with suspected Epiglottitis. Which nursing intervention is
contraindicated?
A. Assessing the throat using a tongue blade
B. Placing the child in a tripod position
C. Preparing for emergency intubation
D. Administering humidified oxygen
Correct Answer: A
Child Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is caring for a client at 34 weeks gestation who presents with sudden, severe
abdominal pain and a rigid, board-like abdomen. Which condition should the nurse suspect?
A. Placenta previa
B. Cervical insufficiency
C. Uterine atony
D. Abruptio placentae
Correct Answer: D
Rationale: Abruptio placentae is characterized by the premature separation of the
placenta from the uterine wall, which causes intense pain and uterine rigidity. Unlike
placenta previa, which presents with painless bright red bleeding, abruption often involves
concealed or dark red bleeding. This is a medical emergency requiring immediate
assessment of maternal stability and fetal well-being.
2. A client receiving Magnesium Sulfate for preeclampsia has a respiratory rate of 10/min and
absent deep tendon reflexes (DTRs). What is the priority nursing action?
A. Increase the infusion rate to stabilize blood pressure
B. Encourage the client to use an incentive spirometer
,C. Administer oxygen via nasal cannula at 2L/min
D. Notify the provider and prepare Calcium Gluconate
Correct Answer: D
Rationale: Magnesium toxicity is indicated by a respiratory rate below 12/min, loss of
deep tendon reflexes, and decreased urinary output. The nurse must immediately stop the
infusion to prevent further toxicity. Calcium gluconate is the pharmacological antagonist
that must be kept at the bedside for such emergencies.
3. Which clinical finding is the most reliable indicator of postpartum hemorrhage in a client
who just delivered a 9lb infant?
A. Increased heart rate and decreased blood pressure
B. Saturation of one perineal pad in 15 minutes
C. A boggy uterus that does not firm with massage
D. A temperature of 100.4 F (38 C) in the first 24 hours
Correct Answer: B
Rationale: The saturation of a perineal pad in 15 minutes or less is a critical indicator of
excessive bleeding. Vital sign changes like tachycardia and hypotension are late signs of
hemorrhage due to the increased blood volume of pregnancy. Uterine atony is the most
common cause, and the nurse must prioritize assessing blood loss volume alongside fundal
tone.
, 4. A nurse is assessing a newborn with suspected Tetralogy of Fallot. Which finding is
characteristic of a ‘Tet spell’?
A. Bounding peripheral pulses in all extremities
B. Profound cyanosis during crying or feeding
C. Wheezing and rales upon lung auscultation
D. Bradycardia and increased intracranial pressure
Correct Answer: B
Rationale: Tetralogy of Fallot involves four heart defects that cause oxygen-poor blood to
flow out of the heart and into the body. A ‘Tet spell’ is a hypercyanotic episode triggered by
activities like crying or feeding that increase oxygen demand. Placing the infant in a knee-
chest position helps increase systemic vascular resistance and improve pulmonary blood
flow during these spells.
5. A pediatric client is admitted with suspected Epiglottitis. Which nursing intervention is
contraindicated?
A. Assessing the throat using a tongue blade
B. Placing the child in a tripod position
C. Preparing for emergency intubation
D. Administering humidified oxygen
Correct Answer: A
