NUR2513/NUR 2513 Exam 2 V3 | Maternal-
Child Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is caring for a client who is at 32 weeks of gestation and is experiencing preterm
labor. Which of the following medications should the nurse expect to administer to promote
fetal lung maturity?
A. Magnesium Sulfate
B. Indomethacin
C. Terbutaline
D. Betamethasone
Correct Answer: D
Rationale: Betamethasone is a glucocorticoid administered to clients in preterm labor to
stimulate the production of surfactant in the fetus. This intervention significantly reduces
the risk of respiratory distress syndrome in the neonate if delivered early. The medication
is typically given in two doses, 24 hours apart, to achieve maximum therapeutic effect.
,2. A nurse is monitoring a client during the first stage of labor. The nurse notes a fetal heart
rate (FHR) pattern with gradual decelerations that begin after the peak of a contraction and
return to baseline after the contraction ends. Which of the following actions should the nurse
take?
A. Assist the client into a side-lying position.
B. Perform a vaginal exam to check for cord prolapse.
C. Increase the rate of the oxytocin infusion.
D. Prepare the client for an immediate vacuum extraction.
Correct Answer: A
Rationale: Late decelerations indicate uteroplacental insufficiency, which poses a risk for
fetal hypoxia. Turning the client to a side-lying position improves blood flow to the
placenta and increases fetal oxygenation. Other priority interventions include stopping
oxytocin, administering oxygen via mask, and increasing IV fluid rates.
3. Which of the following clinical findings should a nurse report immediately for a client
receiving magnesium sulfate for preeclampsia?
A. Urinary output of 40 mL/hr
B. Presence of 2+ deep tendon reflexes
C. Respiratory rate of 10 breaths per minute
D. Client report of feeling warm and flushed
,Correct Answer: C
Rationale: Magnesium sulfate is a central nervous system depressant, and respiratory
depression (less than 12 breaths per minute) is a sign of toxicity. The nurse must also
monitor for loss of deep tendon reflexes and a significant drop in urinary output. If toxicity
is suspected, the infusion should be stopped and calcium gluconate should be administered
as the antidote.
4. A nurse is teaching a pregnant client who has a prescription for an iron supplement. Which
of the following instructions should the nurse include?
A. Take the medication with a glass of milk.
B. Take the medication with orange juice.
C. Expect stools to be light clay-colored.
D. Decrease fiber intake to prevent diarrhea.
Correct Answer: B
Rationale: Vitamin C, found in orange juice, significantly enhances the absorption of iron
supplements. Clients should avoid taking iron with calcium or caffeine, as these substances
inhibit absorption. Stools are expected to be dark green or black, and fiber intake should be
increased to combat the common side effect of constipation.
5. A nurse is assessing a newborn 1 hour after birth. Which of the following findings should
the nurse report to the provider?
A. Nasal flaring and grunting
, B. Heart rate of 145 beats per minute
C. Generalized petechiae
D. Acrocyanosis of the hands and feet
Correct Answer: A
Rationale: Nasal flaring, grunting, and intercostal retractions are classic signs of
respiratory distress in a neonate. While acrocyanosis is a normal finding in the first 24 to
48 hours, respiratory effort should be quiet and effortless. Prompt intervention is required
to ensure adequate oxygenation and prevent respiratory failure.
6. A nurse is caring for a client in the fourth stage of labor. The nurse notes the fundus is
boggy and displaced to the right. Which of the following actions should the nurse take first?
A. Assist the client to the bathroom to void.
B. Administer oxytocin.
C. Massage the fundus.
D. Check the client’s blood pressure.
Correct Answer: A
Rationale: A fundus that is displaced to the right is a classic sign of bladder distention,
which prevents the uterus from contracting effectively. Assisting the client to empty their
bladder will allow the uterus to return to the midline and firm up. If the fundus remains
Child Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is caring for a client who is at 32 weeks of gestation and is experiencing preterm
labor. Which of the following medications should the nurse expect to administer to promote
fetal lung maturity?
A. Magnesium Sulfate
B. Indomethacin
C. Terbutaline
D. Betamethasone
Correct Answer: D
Rationale: Betamethasone is a glucocorticoid administered to clients in preterm labor to
stimulate the production of surfactant in the fetus. This intervention significantly reduces
the risk of respiratory distress syndrome in the neonate if delivered early. The medication
is typically given in two doses, 24 hours apart, to achieve maximum therapeutic effect.
,2. A nurse is monitoring a client during the first stage of labor. The nurse notes a fetal heart
rate (FHR) pattern with gradual decelerations that begin after the peak of a contraction and
return to baseline after the contraction ends. Which of the following actions should the nurse
take?
A. Assist the client into a side-lying position.
B. Perform a vaginal exam to check for cord prolapse.
C. Increase the rate of the oxytocin infusion.
D. Prepare the client for an immediate vacuum extraction.
Correct Answer: A
Rationale: Late decelerations indicate uteroplacental insufficiency, which poses a risk for
fetal hypoxia. Turning the client to a side-lying position improves blood flow to the
placenta and increases fetal oxygenation. Other priority interventions include stopping
oxytocin, administering oxygen via mask, and increasing IV fluid rates.
3. Which of the following clinical findings should a nurse report immediately for a client
receiving magnesium sulfate for preeclampsia?
A. Urinary output of 40 mL/hr
B. Presence of 2+ deep tendon reflexes
C. Respiratory rate of 10 breaths per minute
D. Client report of feeling warm and flushed
,Correct Answer: C
Rationale: Magnesium sulfate is a central nervous system depressant, and respiratory
depression (less than 12 breaths per minute) is a sign of toxicity. The nurse must also
monitor for loss of deep tendon reflexes and a significant drop in urinary output. If toxicity
is suspected, the infusion should be stopped and calcium gluconate should be administered
as the antidote.
4. A nurse is teaching a pregnant client who has a prescription for an iron supplement. Which
of the following instructions should the nurse include?
A. Take the medication with a glass of milk.
B. Take the medication with orange juice.
C. Expect stools to be light clay-colored.
D. Decrease fiber intake to prevent diarrhea.
Correct Answer: B
Rationale: Vitamin C, found in orange juice, significantly enhances the absorption of iron
supplements. Clients should avoid taking iron with calcium or caffeine, as these substances
inhibit absorption. Stools are expected to be dark green or black, and fiber intake should be
increased to combat the common side effect of constipation.
5. A nurse is assessing a newborn 1 hour after birth. Which of the following findings should
the nurse report to the provider?
A. Nasal flaring and grunting
, B. Heart rate of 145 beats per minute
C. Generalized petechiae
D. Acrocyanosis of the hands and feet
Correct Answer: A
Rationale: Nasal flaring, grunting, and intercostal retractions are classic signs of
respiratory distress in a neonate. While acrocyanosis is a normal finding in the first 24 to
48 hours, respiratory effort should be quiet and effortless. Prompt intervention is required
to ensure adequate oxygenation and prevent respiratory failure.
6. A nurse is caring for a client in the fourth stage of labor. The nurse notes the fundus is
boggy and displaced to the right. Which of the following actions should the nurse take first?
A. Assist the client to the bathroom to void.
B. Administer oxytocin.
C. Massage the fundus.
D. Check the client’s blood pressure.
Correct Answer: A
Rationale: A fundus that is displaced to the right is a classic sign of bladder distention,
which prevents the uterus from contracting effectively. Assisting the client to empty their
bladder will allow the uterus to return to the midline and firm up. If the fundus remains
