NUR2513/NUR 2513 Exam 2 V2 | Maternal-
Child Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is monitoring a client in labor and notes late decelerations on the fetal heart rate
monitor. Which of the following is the priority nursing action?
A. Document the findings as a normal physiological response.
B. Increase the rate of the intravenous oxytocin infusion.
C. Administer oxygen at 8 to 10 L/min via a nonrebreather mask.
D. Place the client in a supine position to improve blood flow.
Correct Answer: C
Rationale: Late decelerations are indicative of uteroplacental insufficiency, which poses a
significant risk to fetal oxygenation. The priority action is to improve fetal oxygenation by
administering high-flow oxygen and repositioning the mother to the left side. These
interventions are critical to prevent fetal hypoxia and metabolic acidosis during the
intrapartum period.
2. A patient at 32 weeks gestation is diagnosed with preeclampsia. Which medication should
the nurse anticipate administering to promote fetal lung maturity?
A. Magnesium sulfate
B. Nifedipine
,C. Terbutaline
D. Betamethasone
Correct Answer: D
Rationale: Betamethasone is a corticosteroid administered to the mother to stimulate the
production of surfactant in the fetal lungs. This treatment is essential for reducing the risk
of respiratory distress syndrome if the infant is born prematurely. The standard regimen
involves two doses given 24 hours apart to maximize therapeutic benefits.
3. Which of the following clinical findings should a nurse report immediately for a client
receiving magnesium sulfate for preeclampsia?
A. Respiratory rate of 10 breaths per minute
B. Urinary output of 40 mL per hour
C. Deep tendon reflexes of 2+
D. Blood pressure of 140/90 mmHg
Correct Answer: A
Rationale: A respiratory rate of 10 breaths per minute indicates magnesium toxicity, as the
therapeutic range for magnesium sulfate is narrow. The nurse must monitor for decreased
reflexes, respiratory depression, and oliguria to prevent cardiovascular collapse. If toxicity
is suspected, the infusion must be stopped and calcium gluconate should be readily
available as the antidote.
, 4. A nurse is caring for a client in the fourth stage of labor. The nurse notes that the fundus is
boggy and displaced to the right. Which action should the nurse take first?
A. Encourage the client to void or catheterize if necessary.
B. Administer methylergonovine intramuscularly.
C. Perform vigorous fundal massage.
D. Call the healthcare provider for surgical intervention.
Correct Answer: A
Rationale: A fundus that is displaced to the right and boggy often indicates a full bladder,
which prevents the uterus from contracting effectively. Encouraging the patient to empty
their bladder allows the uterus to return to the midline and firm up, reducing the risk of
postpartum hemorrhage. This is a primary nursing intervention in the immediate
postpartum period to ensure uterine atony is addressed.
5. A nurse is assessing a newborn 1 minute after birth. The heart rate is 110 bpm, the baby
has a weak cry, some flexion of extremities, is grimacing, and has a pink body with blue
extremities. What is the APGAR score?
A. Score of 6
B. Score of 5
C. Score of 7
D. Score of 8
Child Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is monitoring a client in labor and notes late decelerations on the fetal heart rate
monitor. Which of the following is the priority nursing action?
A. Document the findings as a normal physiological response.
B. Increase the rate of the intravenous oxytocin infusion.
C. Administer oxygen at 8 to 10 L/min via a nonrebreather mask.
D. Place the client in a supine position to improve blood flow.
Correct Answer: C
Rationale: Late decelerations are indicative of uteroplacental insufficiency, which poses a
significant risk to fetal oxygenation. The priority action is to improve fetal oxygenation by
administering high-flow oxygen and repositioning the mother to the left side. These
interventions are critical to prevent fetal hypoxia and metabolic acidosis during the
intrapartum period.
2. A patient at 32 weeks gestation is diagnosed with preeclampsia. Which medication should
the nurse anticipate administering to promote fetal lung maturity?
A. Magnesium sulfate
B. Nifedipine
,C. Terbutaline
D. Betamethasone
Correct Answer: D
Rationale: Betamethasone is a corticosteroid administered to the mother to stimulate the
production of surfactant in the fetal lungs. This treatment is essential for reducing the risk
of respiratory distress syndrome if the infant is born prematurely. The standard regimen
involves two doses given 24 hours apart to maximize therapeutic benefits.
3. Which of the following clinical findings should a nurse report immediately for a client
receiving magnesium sulfate for preeclampsia?
A. Respiratory rate of 10 breaths per minute
B. Urinary output of 40 mL per hour
C. Deep tendon reflexes of 2+
D. Blood pressure of 140/90 mmHg
Correct Answer: A
Rationale: A respiratory rate of 10 breaths per minute indicates magnesium toxicity, as the
therapeutic range for magnesium sulfate is narrow. The nurse must monitor for decreased
reflexes, respiratory depression, and oliguria to prevent cardiovascular collapse. If toxicity
is suspected, the infusion must be stopped and calcium gluconate should be readily
available as the antidote.
, 4. A nurse is caring for a client in the fourth stage of labor. The nurse notes that the fundus is
boggy and displaced to the right. Which action should the nurse take first?
A. Encourage the client to void or catheterize if necessary.
B. Administer methylergonovine intramuscularly.
C. Perform vigorous fundal massage.
D. Call the healthcare provider for surgical intervention.
Correct Answer: A
Rationale: A fundus that is displaced to the right and boggy often indicates a full bladder,
which prevents the uterus from contracting effectively. Encouraging the patient to empty
their bladder allows the uterus to return to the midline and firm up, reducing the risk of
postpartum hemorrhage. This is a primary nursing intervention in the immediate
postpartum period to ensure uterine atony is addressed.
5. A nurse is assessing a newborn 1 minute after birth. The heart rate is 110 bpm, the baby
has a weak cry, some flexion of extremities, is grimacing, and has a pink body with blue
extremities. What is the APGAR score?
A. Score of 6
B. Score of 5
C. Score of 7
D. Score of 8
