NUR 2513 MATERNAL CHILD NURSING EXAM 1 TESTBANK
LATEST WITH 300+ QUESTIONS AND ANSWERS|AGRADE
(RASMUSSEN COLLEGE)
1. A nurse is providing education to a client who is in her first trimester of pregnancy.
Which of the following statements by the client indicates a need for further teaching
regarding nutritional needs?
A) "I should increase my protein intake for the baby's growth."
B) "I will need to take an iron supplement as prescribed."
C) "I can continue to eat soft cheeses like brie and feta."
D) "I should aim for about 300 extra calories per day in my second and third
trimesters."
Correct Answer: C) "I can continue to eat soft cheeses like brie and feta."
Rationale: Soft cheeses (like brie, feta, blue cheese, queso fresco) are often
unpasteurized and can harbor Listeria monocytogenes, a bacterium that can cause
listeriosis, which is dangerous during pregnancy. Pregnant clients should avoid these
cheeses unless confirmed to be made from pasteurized milk.
2. A nurse is assessing a pregnant client for presumptive signs of pregnancy. Which of the
following findings would the nurse include?
A) Positive pregnancy test.
B) Fetal heart tones heard via Doppler.
C) Nausea and vomiting.
D) Visualization of fetus on ultrasound.
Correct Answer: C) Nausea and vomiting.
Rationale: Presumptive signs of pregnancy are subjective changes reported by the
client (e.g., amenorrhea, nausea/vomiting, breast tenderness, fatigue, quickening). A
positive pregnancy test is a probable sign. Fetal heart tones and visualization on
ultrasound are positive signs.
3. A nurse is caring for a client in the first trimester of pregnancy. The client reports
frequent urination. The nurse should explain that this is primarily due to:
A) Increased kidney function.
B) Pressure of the enlarging uterus on the bladder.
, C) Hormonal changes.
D) Increased fluid intake.
Correct Answer: B) Pressure of the enlarging uterus on the bladder.
Rationale: In the first trimester, the enlarging uterus puts pressure on the bladder,
leading to increased urinary frequency. This usually subsides in the second trimester as
the uterus rises into the abdominal cavity, but returns in the third trimester as the
presenting part descends.
4. A nurse is teaching a pregnant client about warning signs to report immediately. Which
of the following signs should the nurse emphasize as critical?
A) Nausea that occurs only in the morning.
B) Mild Braxton Hicks contractions.
C) Swelling in the ankles at the end of the day.
D) Sudden onset of severe headache and blurred vision.
Correct Answer: D) Sudden onset of severe headache and blurred vision.
Rationale: Sudden onset of severe headache and blurred vision are classic warning
signs of preeclampsia, a serious hypertensive disorder of pregnancy, and require
immediate medical evaluation. Other options are typically normal or less urgent
discomforts.
5. A client who is 38 weeks gestation comes to the labor and delivery unit reporting
regular contractions that are becoming stronger and closer together. On examination,
the cervix is 4 cm dilated, 80% effaced, and the fetal head is at -1 station. The nurse
should interpret these findings as:
A) False labor.
B) Latent phase of labor.
C) Active phase of labor.
D) Transition phase of labor.
Correct Answer: C) Active phase of labor.
Rationale: The active phase of the first stage of labor is characterized by cervical
dilation from 4 cm to 7 cm, along with stronger, more frequent, and longer
contractions. Latent phase is 0-3 cm, and transition is 8-10 cm.
,6. A nurse is providing education on comfort measures for a client experiencing backache
during pregnancy. Which of the following recommendations should the nurse include?
A) Wear high-heeled shoes for support.
B) Lie flat on the back for prolonged periods.
C) Apply a heating pad to the lower back.
D) Perform pelvic tilt exercises.
Correct Answer: D) Perform pelvic tilt exercises.
Rationale: Pelvic tilt exercises (also known as "pelvic rocking") help strengthen
abdominal muscles and relieve pressure on the lower back, providing relief from
pregnancy-related backaches. High heels, lying flat (supine hypotension), and prolonged
heating pad use are not recommended.
7. A client who is 30 weeks gestation is diagnosed with gestational diabetes. The nurse
should anticipate that the client will need:
A) To avoid all carbohydrates in her diet.
B) Daily insulin injections for the remainder of the pregnancy.
C) Dietary modifications and possibly insulin therapy if glucose levels are not controlled.
D) To deliver the baby by cesarean section.
Correct Answer: C) Dietary modifications and possibly insulin therapy if glucose
levels are not controlled.
Rationale: Initial management of gestational diabetes usually involves therapeutic
lifestyle changes, primarily dietary modifications. If blood glucose levels remain elevated
despite diet, insulin therapy (or oral antihyperglycemic agents) may be initiated. Not all
clients require insulin, and not all require a C-section.
8. A nurse is teaching a postpartum client about preventing mastitis. Which of the
following instructions should the nurse provide?
A) Wear a tight-fitting bra to suppress milk production.
B) Breastfeed infrequently to allow breasts to rest.
C) Ensure complete emptying of the breasts with each feeding.
D) Stop breastfeeding if signs of redness or tenderness appear.
Correct Answer: C) Ensure complete emptying of the breasts with each feeding.
, Rationale: Incomplete emptying of the breasts is a major risk factor for mastitis (breast
infection). Ensuring complete emptying, regular and frequent feedings, and proper latch
are key preventive measures.
9. A nurse is performing a newborn assessment. Which of the following findings would be
considered a normal physiological adaptation?
A) Jaundice noted at 4 hours of age.
B) Respiratory rate of 50 breaths/min with short periods of apnea (less than 15
seconds).
C) Heart rate of 80 beats/min at rest.
D) A single umbilical artery.
Correct Answer: B) Respiratory rate of 50 breaths/min with short periods of apnea
(less than 15 seconds).
Rationale: Newborns typically have irregular respiratory patterns with a rate between
30-60 breaths/min, and short periods of apnea (less than 15 seconds) are normal.
Jaundice within the first 24 hours (pathological), bradycardia (normal is 110-160 bpm),
and a single umbilical artery (associated with anomalies) are abnormal.
10. A nurse is providing education to a pregnant client about fetal development. At what
gestational age is the fetal heart beat typically audible by Doppler?
A) 4 weeks.
B) 8-12 weeks.
C) 16-20 weeks.
D) 24 weeks.
Correct Answer: B) 8-12 weeks.
Rationale: Fetal heart tones are typically audible by Doppler ultrasound between 8 and
12 weeks of gestation. Fetal movement (quickening) is usually felt by the mother around
16-20 weeks.
11. A client who is 28 weeks gestation reports that she feels dizzy when lying on her back.
The nurse should explain that this is due to:
A) Iron deficiency anemia.
B) Supine hypotensive syndrome.
LATEST WITH 300+ QUESTIONS AND ANSWERS|AGRADE
(RASMUSSEN COLLEGE)
1. A nurse is providing education to a client who is in her first trimester of pregnancy.
Which of the following statements by the client indicates a need for further teaching
regarding nutritional needs?
A) "I should increase my protein intake for the baby's growth."
B) "I will need to take an iron supplement as prescribed."
C) "I can continue to eat soft cheeses like brie and feta."
D) "I should aim for about 300 extra calories per day in my second and third
trimesters."
Correct Answer: C) "I can continue to eat soft cheeses like brie and feta."
Rationale: Soft cheeses (like brie, feta, blue cheese, queso fresco) are often
unpasteurized and can harbor Listeria monocytogenes, a bacterium that can cause
listeriosis, which is dangerous during pregnancy. Pregnant clients should avoid these
cheeses unless confirmed to be made from pasteurized milk.
2. A nurse is assessing a pregnant client for presumptive signs of pregnancy. Which of the
following findings would the nurse include?
A) Positive pregnancy test.
B) Fetal heart tones heard via Doppler.
C) Nausea and vomiting.
D) Visualization of fetus on ultrasound.
Correct Answer: C) Nausea and vomiting.
Rationale: Presumptive signs of pregnancy are subjective changes reported by the
client (e.g., amenorrhea, nausea/vomiting, breast tenderness, fatigue, quickening). A
positive pregnancy test is a probable sign. Fetal heart tones and visualization on
ultrasound are positive signs.
3. A nurse is caring for a client in the first trimester of pregnancy. The client reports
frequent urination. The nurse should explain that this is primarily due to:
A) Increased kidney function.
B) Pressure of the enlarging uterus on the bladder.
, C) Hormonal changes.
D) Increased fluid intake.
Correct Answer: B) Pressure of the enlarging uterus on the bladder.
Rationale: In the first trimester, the enlarging uterus puts pressure on the bladder,
leading to increased urinary frequency. This usually subsides in the second trimester as
the uterus rises into the abdominal cavity, but returns in the third trimester as the
presenting part descends.
4. A nurse is teaching a pregnant client about warning signs to report immediately. Which
of the following signs should the nurse emphasize as critical?
A) Nausea that occurs only in the morning.
B) Mild Braxton Hicks contractions.
C) Swelling in the ankles at the end of the day.
D) Sudden onset of severe headache and blurred vision.
Correct Answer: D) Sudden onset of severe headache and blurred vision.
Rationale: Sudden onset of severe headache and blurred vision are classic warning
signs of preeclampsia, a serious hypertensive disorder of pregnancy, and require
immediate medical evaluation. Other options are typically normal or less urgent
discomforts.
5. A client who is 38 weeks gestation comes to the labor and delivery unit reporting
regular contractions that are becoming stronger and closer together. On examination,
the cervix is 4 cm dilated, 80% effaced, and the fetal head is at -1 station. The nurse
should interpret these findings as:
A) False labor.
B) Latent phase of labor.
C) Active phase of labor.
D) Transition phase of labor.
Correct Answer: C) Active phase of labor.
Rationale: The active phase of the first stage of labor is characterized by cervical
dilation from 4 cm to 7 cm, along with stronger, more frequent, and longer
contractions. Latent phase is 0-3 cm, and transition is 8-10 cm.
,6. A nurse is providing education on comfort measures for a client experiencing backache
during pregnancy. Which of the following recommendations should the nurse include?
A) Wear high-heeled shoes for support.
B) Lie flat on the back for prolonged periods.
C) Apply a heating pad to the lower back.
D) Perform pelvic tilt exercises.
Correct Answer: D) Perform pelvic tilt exercises.
Rationale: Pelvic tilt exercises (also known as "pelvic rocking") help strengthen
abdominal muscles and relieve pressure on the lower back, providing relief from
pregnancy-related backaches. High heels, lying flat (supine hypotension), and prolonged
heating pad use are not recommended.
7. A client who is 30 weeks gestation is diagnosed with gestational diabetes. The nurse
should anticipate that the client will need:
A) To avoid all carbohydrates in her diet.
B) Daily insulin injections for the remainder of the pregnancy.
C) Dietary modifications and possibly insulin therapy if glucose levels are not controlled.
D) To deliver the baby by cesarean section.
Correct Answer: C) Dietary modifications and possibly insulin therapy if glucose
levels are not controlled.
Rationale: Initial management of gestational diabetes usually involves therapeutic
lifestyle changes, primarily dietary modifications. If blood glucose levels remain elevated
despite diet, insulin therapy (or oral antihyperglycemic agents) may be initiated. Not all
clients require insulin, and not all require a C-section.
8. A nurse is teaching a postpartum client about preventing mastitis. Which of the
following instructions should the nurse provide?
A) Wear a tight-fitting bra to suppress milk production.
B) Breastfeed infrequently to allow breasts to rest.
C) Ensure complete emptying of the breasts with each feeding.
D) Stop breastfeeding if signs of redness or tenderness appear.
Correct Answer: C) Ensure complete emptying of the breasts with each feeding.
, Rationale: Incomplete emptying of the breasts is a major risk factor for mastitis (breast
infection). Ensuring complete emptying, regular and frequent feedings, and proper latch
are key preventive measures.
9. A nurse is performing a newborn assessment. Which of the following findings would be
considered a normal physiological adaptation?
A) Jaundice noted at 4 hours of age.
B) Respiratory rate of 50 breaths/min with short periods of apnea (less than 15
seconds).
C) Heart rate of 80 beats/min at rest.
D) A single umbilical artery.
Correct Answer: B) Respiratory rate of 50 breaths/min with short periods of apnea
(less than 15 seconds).
Rationale: Newborns typically have irregular respiratory patterns with a rate between
30-60 breaths/min, and short periods of apnea (less than 15 seconds) are normal.
Jaundice within the first 24 hours (pathological), bradycardia (normal is 110-160 bpm),
and a single umbilical artery (associated with anomalies) are abnormal.
10. A nurse is providing education to a pregnant client about fetal development. At what
gestational age is the fetal heart beat typically audible by Doppler?
A) 4 weeks.
B) 8-12 weeks.
C) 16-20 weeks.
D) 24 weeks.
Correct Answer: B) 8-12 weeks.
Rationale: Fetal heart tones are typically audible by Doppler ultrasound between 8 and
12 weeks of gestation. Fetal movement (quickening) is usually felt by the mother around
16-20 weeks.
11. A client who is 28 weeks gestation reports that she feels dizzy when lying on her back.
The nurse should explain that this is due to:
A) Iron deficiency anemia.
B) Supine hypotensive syndrome.
