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 36 weeks of gestation and has a prescription for a
nonstress test (NST). Which of the following results should the nurse identify as a reactive
NST?
A. Fetal heart rate shows persistent late decelerations during the recording period.
B. Two or more accelerations of 15 beats/min lasting 15 seconds in a 20-minute period.
C. Fetal heart rate accelerations of 10 beats/min lasting 10 seconds in a 40-minute period.
D. Presence of variable decelerations that occur with more than 50% of contractions.
Correct Answer: B
Rationale: A reactive nonstress test is defined by the presence of at least two fetal heart
rate accelerations within a 20-minute window. Each acceleration must peak at least 15
beats per minute above the baseline and last for at least 15 seconds. This finding indicates
fetal well-being and adequate oxygenation through the placenta.
2. A nurse is monitoring a client who is receiving magnesium sulfate via continuous IV
infusion for preeclampsia. Which of the following findings should the nurse report to the
provider immediately?
A. Blood pressure of 148/92 mmHg.
,B. Deep tendon reflexes of 2+.
C. Fetal heart rate baseline of 130 beats/min.
D. Urinary output of 20 mL/hr over the last 2 hours.
Correct Answer: D
Rationale: Magnesium sulfate is excreted by the kidneys, and a decrease in urinary output
can lead to toxic levels of the medication. The nurse should report any output less than 30
mL/hr as it may indicate renal impairment or impending magnesium toxicity. Monitoring
urine output is a critical safety measure when administering high-dose magnesium
infusions.
3. A nurse is assessing a newborn 1 hour after birth. Which of the following findings should
the nurse report to the provider?
A. Respiratory rate of 48 breaths/min.
B. Generalized cyanosis of the trunk and extremities.
C. Acrocyanosis of the hands and feet.
D. Axillary temperature of 36.8°C (98.2°F).
Correct Answer: B
Rationale: Generalized cyanosis or central cyanosis involves the trunk and mucous
membranes and is a sign of respiratory or cardiac distress. Acrocyanosis is common and
normal in the first 24 to 48 hours of life, but central cyanosis is always an emergency. The
,nurse must immediately notify the provider and initiate stabilization measures like oxygen
administration.
4. A nurse is caring for a client who is in the first stage of labor and has a fetal heart rate
tracing showing late decelerations. Which of the following actions should the nurse take first?
A. Perform a sterile vaginal examination.
B. Increase the rate of the maintenance IV fluid.
C. Assist the client into a side-lying position.
D. Administer oxygen at 10 L/min via nonrebreather mask.
Correct Answer: C
Rationale: Late decelerations are caused by uteroplacental insufficiency and indicate that
the fetus is not receiving enough oxygen during contractions. The priority nursing action is
to turn the client to their side to displace the uterus from the vena cava and improve blood
flow. After repositioning, the nurse should follow up with oxygen therapy and IV fluid
boluses if necessary.
5. A nurse is teaching a parent of a 2-year-old child about safety. Which of the following
instructions should the nurse include in the teaching?
A. Switch the child to a forward-facing car seat immediately.
B. Place the child in a booster seat when they reach 30 pounds.
C. Keep the water heater temperature set at 49°C (120°F) or less.
, D. Allow the child to play with small balloons under supervision.
Correct Answer: C
Rationale: Toddlers are at high risk for burns due to their curiosity and developing motor
skills. Setting the water heater to no more than 120 degrees Fahrenheit prevents accidental
scalding during bath time. This safety measure is a standard recommendation for
households with young children to prevent significant injury.
6. A nurse is assessing a client who is 2 hours postpartum. The nurse notes the fundus is
boggy and displaced to the right. Which of the following actions should the nurse take?
A. Administer oxytocin 10 units IM.
B. Perform vigorous fundal massage.
C. Assist the client to the bathroom to void.
D. Prepare the client for a stat ultrasound.
Correct Answer: C
Rationale: A boggy fundus that is displaced to the right is a classic sign of bladder
distention. A full bladder prevents the uterus from contracting effectively, which
significantly increases the risk of postpartum hemorrhage. Assisting the client to empty her
bladder will allow the uterus to return to the midline and firm up.
7. A nurse is assessing a client who has placenta previa. Which of the following clinical
findings should the nurse expect?
A. Rigid, board-like abdomen.
Child Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is caring for a client who is at 36 weeks of gestation and has a prescription for a
nonstress test (NST). Which of the following results should the nurse identify as a reactive
NST?
A. Fetal heart rate shows persistent late decelerations during the recording period.
B. Two or more accelerations of 15 beats/min lasting 15 seconds in a 20-minute period.
C. Fetal heart rate accelerations of 10 beats/min lasting 10 seconds in a 40-minute period.
D. Presence of variable decelerations that occur with more than 50% of contractions.
Correct Answer: B
Rationale: A reactive nonstress test is defined by the presence of at least two fetal heart
rate accelerations within a 20-minute window. Each acceleration must peak at least 15
beats per minute above the baseline and last for at least 15 seconds. This finding indicates
fetal well-being and adequate oxygenation through the placenta.
2. A nurse is monitoring a client who is receiving magnesium sulfate via continuous IV
infusion for preeclampsia. Which of the following findings should the nurse report to the
provider immediately?
A. Blood pressure of 148/92 mmHg.
,B. Deep tendon reflexes of 2+.
C. Fetal heart rate baseline of 130 beats/min.
D. Urinary output of 20 mL/hr over the last 2 hours.
Correct Answer: D
Rationale: Magnesium sulfate is excreted by the kidneys, and a decrease in urinary output
can lead to toxic levels of the medication. The nurse should report any output less than 30
mL/hr as it may indicate renal impairment or impending magnesium toxicity. Monitoring
urine output is a critical safety measure when administering high-dose magnesium
infusions.
3. A nurse is assessing a newborn 1 hour after birth. Which of the following findings should
the nurse report to the provider?
A. Respiratory rate of 48 breaths/min.
B. Generalized cyanosis of the trunk and extremities.
C. Acrocyanosis of the hands and feet.
D. Axillary temperature of 36.8°C (98.2°F).
Correct Answer: B
Rationale: Generalized cyanosis or central cyanosis involves the trunk and mucous
membranes and is a sign of respiratory or cardiac distress. Acrocyanosis is common and
normal in the first 24 to 48 hours of life, but central cyanosis is always an emergency. The
,nurse must immediately notify the provider and initiate stabilization measures like oxygen
administration.
4. A nurse is caring for a client who is in the first stage of labor and has a fetal heart rate
tracing showing late decelerations. Which of the following actions should the nurse take first?
A. Perform a sterile vaginal examination.
B. Increase the rate of the maintenance IV fluid.
C. Assist the client into a side-lying position.
D. Administer oxygen at 10 L/min via nonrebreather mask.
Correct Answer: C
Rationale: Late decelerations are caused by uteroplacental insufficiency and indicate that
the fetus is not receiving enough oxygen during contractions. The priority nursing action is
to turn the client to their side to displace the uterus from the vena cava and improve blood
flow. After repositioning, the nurse should follow up with oxygen therapy and IV fluid
boluses if necessary.
5. A nurse is teaching a parent of a 2-year-old child about safety. Which of the following
instructions should the nurse include in the teaching?
A. Switch the child to a forward-facing car seat immediately.
B. Place the child in a booster seat when they reach 30 pounds.
C. Keep the water heater temperature set at 49°C (120°F) or less.
, D. Allow the child to play with small balloons under supervision.
Correct Answer: C
Rationale: Toddlers are at high risk for burns due to their curiosity and developing motor
skills. Setting the water heater to no more than 120 degrees Fahrenheit prevents accidental
scalding during bath time. This safety measure is a standard recommendation for
households with young children to prevent significant injury.
6. A nurse is assessing a client who is 2 hours postpartum. The nurse notes the fundus is
boggy and displaced to the right. Which of the following actions should the nurse take?
A. Administer oxytocin 10 units IM.
B. Perform vigorous fundal massage.
C. Assist the client to the bathroom to void.
D. Prepare the client for a stat ultrasound.
Correct Answer: C
Rationale: A boggy fundus that is displaced to the right is a classic sign of bladder
distention. A full bladder prevents the uterus from contracting effectively, which
significantly increases the risk of postpartum hemorrhage. Assisting the client to empty her
bladder will allow the uterus to return to the midline and firm up.
7. A nurse is assessing a client who has placenta previa. Which of the following clinical
findings should the nurse expect?
A. Rigid, board-like abdomen.
