NUR2513/NUR 2513 Exam 2 V2 | Maternal
Child Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is caring for a client who is in the first stage of labor and is experiencing back labor.
Which of the following non-pharmacological interventions should the nurse perform?
A. Perform effleurage on the abdomen
B. Instruct the client to use patterned-paced breathing
C. Encourage the client to remain in a supine position
D. Apply counterpressure to the sacral area
Correct Answer: D
Rationale: Counterpressure is a physical technique where steady pressure is applied by a
support person to the sacral area with the fist or heel of the hand. This technique helps
relieve back pain caused by the fetal head pressing against the mother’s spine, commonly
seen in occiput posterior positions. It is a highly effective non-pharmacological comfort
measure during the first stage of labor.
2. A nurse is assessing a newborn 1 hour after birth. Which of the following findings should
the nurse report to the provider?
A. Acrocyanosis of the hands and feet
B. Respiratory rate of 50/min
,C. Generalized petechiae over the body
D. A single transverse palmar crease
Correct Answer: C
Rationale: Generalized petechiae can indicate a serious underlying condition such as
infection or a clotting deficiency in the newborn. While acrocyanosis is normal in the first
24-48 hours, petechiae are not a standard finding. A single transverse palmar crease is
often associated with Down syndrome and requires follow-up, but generalized petechiae
represent a more acute physiological concern.
3. A client who is at 38 weeks of gestation is receiving magnesium sulfate IV for preeclampsia.
The nurse notes a respiratory rate of 10/min and absent deep tendon reflexes. Which of the
following actions should the nurse take?
A. Administer calcium gluconate IV
B. Increase the IV fluid rate
C. Place the client in Trendelenburg position
D. Prepare for immediate vaginal delivery
Correct Answer: A
Rationale: Calcium gluconate is the specific antidote for magnesium sulfate toxicity and
should be administered immediately when signs of toxicity appear. Signs of magnesium
toxicity include a respiratory rate less than 12/min, loss of deep tendon reflexes, and
,decreased urinary output. The nurse must also stop the magnesium infusion immediately
to prevent further respiratory depression.
4. A nurse is monitoring a client in labor who has a fetal heart rate (FHR) tracing showing late
decelerations. Which of the following is the priority nursing action?
A. Increase the rate of the maintenance IV fluid
B. Perform a vaginal examination
C. Administer oxygen at 8 to 10 L/min via nonrebreather mask
D. Turn the client onto her side
Correct Answer: D
Rationale: Late decelerations indicate uteroplacental insufficiency and require immediate
intervention to improve fetal oxygenation. The first action should be to turn the client to a
side-lying position to displace the uterus from the inferior vena cava and improve blood
flow. Subsequent actions include increasing IV fluids and administering oxygen, but
positioning is the most immediate priority.
5. A nurse is providing discharge teaching to a client who is breastfeeding. Which of the
following instructions should the nurse include?
A. Wash nipples with soap and water before each feeding
B. Apply a heating pad to the breasts if engorgement occurs
C. Ensure the baby’s mouth covers the entire nipple and most of the areola
, D. Breastfeed the baby on a strict every-4-hour schedule
Correct Answer: C
Rationale: A proper latch is essential for effective breastfeeding and to prevent nipple
soreness. The infant’s mouth should encompass the nipple and at least 1 inch of the
surrounding areola to ensure adequate suction and milk transfer. Scheduling should be
based on infant hunger cues rather than a rigid clock to support milk supply and infant
growth.
6. A nurse is caring for a client who is 2 hours postpartum and has a boggy uterus with heavy
lochia rubra. Which of the following medications should the nurse expect to administer?
A. Oxytocin
B. Magnesium sulfate
C. Terbutaline
D. Nifedipine
Correct Answer: A
Rationale: Oxytocin is a uterotonic medication used to stimulate uterine contractions and
promote uterine involution. It is the first-line treatment for uterine atony and postpartum
hemorrhage to help firm a boggy uterus. Terbutaline and Magnesium sulfate are actually
used to relax the uterus, which would be contraindicated in this scenario.
Child Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is caring for a client who is in the first stage of labor and is experiencing back labor.
Which of the following non-pharmacological interventions should the nurse perform?
A. Perform effleurage on the abdomen
B. Instruct the client to use patterned-paced breathing
C. Encourage the client to remain in a supine position
D. Apply counterpressure to the sacral area
Correct Answer: D
Rationale: Counterpressure is a physical technique where steady pressure is applied by a
support person to the sacral area with the fist or heel of the hand. This technique helps
relieve back pain caused by the fetal head pressing against the mother’s spine, commonly
seen in occiput posterior positions. It is a highly effective non-pharmacological comfort
measure during the first stage of labor.
2. A nurse is assessing a newborn 1 hour after birth. Which of the following findings should
the nurse report to the provider?
A. Acrocyanosis of the hands and feet
B. Respiratory rate of 50/min
,C. Generalized petechiae over the body
D. A single transverse palmar crease
Correct Answer: C
Rationale: Generalized petechiae can indicate a serious underlying condition such as
infection or a clotting deficiency in the newborn. While acrocyanosis is normal in the first
24-48 hours, petechiae are not a standard finding. A single transverse palmar crease is
often associated with Down syndrome and requires follow-up, but generalized petechiae
represent a more acute physiological concern.
3. A client who is at 38 weeks of gestation is receiving magnesium sulfate IV for preeclampsia.
The nurse notes a respiratory rate of 10/min and absent deep tendon reflexes. Which of the
following actions should the nurse take?
A. Administer calcium gluconate IV
B. Increase the IV fluid rate
C. Place the client in Trendelenburg position
D. Prepare for immediate vaginal delivery
Correct Answer: A
Rationale: Calcium gluconate is the specific antidote for magnesium sulfate toxicity and
should be administered immediately when signs of toxicity appear. Signs of magnesium
toxicity include a respiratory rate less than 12/min, loss of deep tendon reflexes, and
,decreased urinary output. The nurse must also stop the magnesium infusion immediately
to prevent further respiratory depression.
4. A nurse is monitoring a client in labor who has a fetal heart rate (FHR) tracing showing late
decelerations. Which of the following is the priority nursing action?
A. Increase the rate of the maintenance IV fluid
B. Perform a vaginal examination
C. Administer oxygen at 8 to 10 L/min via nonrebreather mask
D. Turn the client onto her side
Correct Answer: D
Rationale: Late decelerations indicate uteroplacental insufficiency and require immediate
intervention to improve fetal oxygenation. The first action should be to turn the client to a
side-lying position to displace the uterus from the inferior vena cava and improve blood
flow. Subsequent actions include increasing IV fluids and administering oxygen, but
positioning is the most immediate priority.
5. A nurse is providing discharge teaching to a client who is breastfeeding. Which of the
following instructions should the nurse include?
A. Wash nipples with soap and water before each feeding
B. Apply a heating pad to the breasts if engorgement occurs
C. Ensure the baby’s mouth covers the entire nipple and most of the areola
, D. Breastfeed the baby on a strict every-4-hour schedule
Correct Answer: C
Rationale: A proper latch is essential for effective breastfeeding and to prevent nipple
soreness. The infant’s mouth should encompass the nipple and at least 1 inch of the
surrounding areola to ensure adequate suction and milk transfer. Scheduling should be
based on infant hunger cues rather than a rigid clock to support milk supply and infant
growth.
6. A nurse is caring for a client who is 2 hours postpartum and has a boggy uterus with heavy
lochia rubra. Which of the following medications should the nurse expect to administer?
A. Oxytocin
B. Magnesium sulfate
C. Terbutaline
D. Nifedipine
Correct Answer: A
Rationale: Oxytocin is a uterotonic medication used to stimulate uterine contractions and
promote uterine involution. It is the first-line treatment for uterine atony and postpartum
hemorrhage to help firm a boggy uterus. Terbutaline and Magnesium sulfate are actually
used to relax the uterus, which would be contraindicated in this scenario.
