NUR2513/NUR 2513 Exam 2 V1 | Maternal-
Child Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is caring for a client who is at 34 weeks of gestation and has a prescription for
magnesium sulfate IV to treat preeclampsia. Which of the following findings should the nurse
report to the provider as a sign of magnesium toxicity?
A. Deep tendon reflexes of 2+
B. Urine output of 20 mL/hr
C. Respiratory rate of 14/min
D. Fetal heart rate of 120/min
Correct Answer: B
Rationale: Magnesium sulfate is excreted by the kidneys, so a decrease in urine output
below 30 mL/hr can lead to toxic accumulation. Signs of toxicity include respiratory
depression, loss of deep tendon reflexes, and cardiac arrest. The nurse should immediately
stop the infusion and prepare calcium gluconate if toxicity is suspected.
2. A nurse is assessing a client who is in the third stage of labor. Which of the following
findings indicates placental separation?
A. Decrease in uterine size
B. Decreased vaginal bleeding
,C. Softening of the uterine fundus
D. Lengthening of the umbilical cord
Correct Answer: D
Rationale: Placental separation is typically characterized by a sudden gush of dark blood
from the introitus and the umbilical cord lengthening at the vaginal opening. The uterus
also changes from a discoid to a globular shape as it contracts. These signs occur within
minutes after the birth of the infant and signal that the placenta is ready to be delivered.
3. A nurse is performing a physical assessment of a newborn. Which of the following findings
should the nurse expect?
A. Heart rate of 100/min while sleeping
B. Molding of the cranial bones
C. Chest circumference 2 cm larger than head circumference
D. Positive Babinski reflex lasting until 2 months of age
Correct Answer: B
Rationale: Molding is a common finding caused by the overlapping of cranial bones during
the passage through the birth canal. This usually resolves within a few days after birth
without intervention. Other expected findings include a head circumference that is slightly
larger than the chest circumference.
, 4. A nurse is teaching a client who is at 12 weeks of gestation about an upcoming ultrasound.
Which of the following instructions should the nurse include?
A. Drink a full glass of water every 15 minutes for 1 hour before the test.
B. Avoid eating for 8 hours prior to the procedure.
C. You will need to have a full bladder for the procedure.
D. This test will determine the sex of your baby with 100% accuracy.
Correct Answer: C
Rationale: During the first and second trimesters, a full bladder is necessary to push the
uterus upward for better visualization of the fetus. The nurse should instruct the client to
drink plenty of fluids and refrain from voiding before the ultrasound. This provides a
‘window’ for the sound waves to travel through the pelvic cavity.
5. A nurse is caring for a client who is in active labor and has late decelerations on the fetal
monitor. Which of the following actions should the nurse take first?
A. Administer oxygen via nonrebreather mask at 10 L/min.
B. Increase the IV fluid infusion rate.
C. Notify the provider immediately.
D. Turn the client onto her side.
Correct Answer: D
Child Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is caring for a client who is at 34 weeks of gestation and has a prescription for
magnesium sulfate IV to treat preeclampsia. Which of the following findings should the nurse
report to the provider as a sign of magnesium toxicity?
A. Deep tendon reflexes of 2+
B. Urine output of 20 mL/hr
C. Respiratory rate of 14/min
D. Fetal heart rate of 120/min
Correct Answer: B
Rationale: Magnesium sulfate is excreted by the kidneys, so a decrease in urine output
below 30 mL/hr can lead to toxic accumulation. Signs of toxicity include respiratory
depression, loss of deep tendon reflexes, and cardiac arrest. The nurse should immediately
stop the infusion and prepare calcium gluconate if toxicity is suspected.
2. A nurse is assessing a client who is in the third stage of labor. Which of the following
findings indicates placental separation?
A. Decrease in uterine size
B. Decreased vaginal bleeding
,C. Softening of the uterine fundus
D. Lengthening of the umbilical cord
Correct Answer: D
Rationale: Placental separation is typically characterized by a sudden gush of dark blood
from the introitus and the umbilical cord lengthening at the vaginal opening. The uterus
also changes from a discoid to a globular shape as it contracts. These signs occur within
minutes after the birth of the infant and signal that the placenta is ready to be delivered.
3. A nurse is performing a physical assessment of a newborn. Which of the following findings
should the nurse expect?
A. Heart rate of 100/min while sleeping
B. Molding of the cranial bones
C. Chest circumference 2 cm larger than head circumference
D. Positive Babinski reflex lasting until 2 months of age
Correct Answer: B
Rationale: Molding is a common finding caused by the overlapping of cranial bones during
the passage through the birth canal. This usually resolves within a few days after birth
without intervention. Other expected findings include a head circumference that is slightly
larger than the chest circumference.
, 4. A nurse is teaching a client who is at 12 weeks of gestation about an upcoming ultrasound.
Which of the following instructions should the nurse include?
A. Drink a full glass of water every 15 minutes for 1 hour before the test.
B. Avoid eating for 8 hours prior to the procedure.
C. You will need to have a full bladder for the procedure.
D. This test will determine the sex of your baby with 100% accuracy.
Correct Answer: C
Rationale: During the first and second trimesters, a full bladder is necessary to push the
uterus upward for better visualization of the fetus. The nurse should instruct the client to
drink plenty of fluids and refrain from voiding before the ultrasound. This provides a
‘window’ for the sound waves to travel through the pelvic cavity.
5. A nurse is caring for a client who is in active labor and has late decelerations on the fetal
monitor. Which of the following actions should the nurse take first?
A. Administer oxygen via nonrebreather mask at 10 L/min.
B. Increase the IV fluid infusion rate.
C. Notify the provider immediately.
D. Turn the client onto her side.
Correct Answer: D
