NUR2513/NUR 2513 Exam 2 V3 | Maternal
Child Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is monitoring a client who is receiving magnesium sulfate for preeclampsia. Which
of the following findings should the nurse report to the provider as a sign of magnesium
toxicity?
A. Urinary output of 40 mL/hr
B. Respiratory rate of 10/min
C. Deep tendon reflexes of 2+
D. Blood pressure of 150/95 mmHg
Correct Answer: B
Rationale: A respiratory rate below 12/min is a primary indicator of magnesium sulfate
toxicity. Other signs include absent deep tendon reflexes and a significant decrease in
urinary output. The nurse must monitor these vital parameters frequently to prevent
respiratory arrest.
2. A nurse is caring for a client in the active phase of labor who has a prolapsed umbilical
cord. Which of the following actions should the nurse take first?
A. Apply oxygen via non-rebreather mask at 10 L/min
B. Prepare the client for an immediate cesarean birth
,C. Increase the intravenous fluid infusion rate
D. Perform a vaginal exam and apply upward pressure to the presenting part
Correct Answer: D
Rationale: The priority action is to relieve pressure on the umbilical cord to maintain fetal
oxygenation. The nurse should use a sterile gloved hand to push the presenting part away
from the cord. This intervention is critical until a cesarean delivery can be performed.
3. A nurse is assessing a newborn 1 hour after birth. Which of the following findings should
the nurse identify as a manifestation of respiratory distress?
A. Acrocyanosis
B. Abdominal breathing
C. Respiratory rate of 50/min
D. Nasal flaring
Correct Answer: D
Rationale: Nasal flaring is a classic sign of respiratory distress in a newborn as they
attempt to decrease airway resistance. Other signs include intercostal retractions and
expiratory grunting. Acrocyanosis and abdominal breathing are considered normal
findings in the immediate neonatal period.
, 4. A client at 34 weeks of gestation reports a sudden onset of bright red vaginal bleeding
without pain. The nurse should suspect which of the following complications?
A. Abruptio placentae
B. Placenta previa
C. Preterm labor
D. Vasa previa
Correct Answer: B
Rationale: Placenta previa is characterized by painless, bright red vaginal bleeding during
the second or third trimester. In contrast, abruptio placentae typically presents with
painful bleeding and a rigid abdomen. Management involves bed rest and monitoring fetal
well-being.
5. A nurse is caring for a client who is postpartum and has a boggy uterus with heavy lochia
rubra. Which of the following medications should the nurse anticipate administering?
A. Magnesium sulfate
B. Oxytocin
C. Terbutaline
D. Betamethasone
Correct Answer: B
Child Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is monitoring a client who is receiving magnesium sulfate for preeclampsia. Which
of the following findings should the nurse report to the provider as a sign of magnesium
toxicity?
A. Urinary output of 40 mL/hr
B. Respiratory rate of 10/min
C. Deep tendon reflexes of 2+
D. Blood pressure of 150/95 mmHg
Correct Answer: B
Rationale: A respiratory rate below 12/min is a primary indicator of magnesium sulfate
toxicity. Other signs include absent deep tendon reflexes and a significant decrease in
urinary output. The nurse must monitor these vital parameters frequently to prevent
respiratory arrest.
2. A nurse is caring for a client in the active phase of labor who has a prolapsed umbilical
cord. Which of the following actions should the nurse take first?
A. Apply oxygen via non-rebreather mask at 10 L/min
B. Prepare the client for an immediate cesarean birth
,C. Increase the intravenous fluid infusion rate
D. Perform a vaginal exam and apply upward pressure to the presenting part
Correct Answer: D
Rationale: The priority action is to relieve pressure on the umbilical cord to maintain fetal
oxygenation. The nurse should use a sterile gloved hand to push the presenting part away
from the cord. This intervention is critical until a cesarean delivery can be performed.
3. A nurse is assessing a newborn 1 hour after birth. Which of the following findings should
the nurse identify as a manifestation of respiratory distress?
A. Acrocyanosis
B. Abdominal breathing
C. Respiratory rate of 50/min
D. Nasal flaring
Correct Answer: D
Rationale: Nasal flaring is a classic sign of respiratory distress in a newborn as they
attempt to decrease airway resistance. Other signs include intercostal retractions and
expiratory grunting. Acrocyanosis and abdominal breathing are considered normal
findings in the immediate neonatal period.
, 4. A client at 34 weeks of gestation reports a sudden onset of bright red vaginal bleeding
without pain. The nurse should suspect which of the following complications?
A. Abruptio placentae
B. Placenta previa
C. Preterm labor
D. Vasa previa
Correct Answer: B
Rationale: Placenta previa is characterized by painless, bright red vaginal bleeding during
the second or third trimester. In contrast, abruptio placentae typically presents with
painful bleeding and a rigid abdomen. Management involves bed rest and monitoring fetal
well-being.
5. A nurse is caring for a client who is postpartum and has a boggy uterus with heavy lochia
rubra. Which of the following medications should the nurse anticipate administering?
A. Magnesium sulfate
B. Oxytocin
C. Terbutaline
D. Betamethasone
Correct Answer: B
