(LATEST 2026) MATERNAL-CHILD
NURSING EXAM | QUESTIONS AND
VERIFIED ANSWERS| GRADED A -
RASMUSSEN
1. The nurse in labor and delivery is monitoring a client at 38 weeks gestation who
presents for a nonstress test (NST). In performing a nonstress test, the nurse will
observe for and document which of the following? (SATA)
a. Accelerations in the fetal heart rate
b. Amount of amniotic fluid
c. Fetal tone
d. Decelerations in the fetal heart rate
e. Variability in the fetal heart rate
Answer: a. Accelerations in the fetal heart rate, d. Decelerations in the fetal heart
rate, e. Variability in the fetal heart rate
Rationale: A nonstress test monitors fetal well-being by assessing the fetal heart rate
in response to fetal movements. Accelerations are a sign of fetal health, decelerations
may indicate stress, and variability reflects autonomic nervous system maturity.
Amniotic fluid and fetal tone are assessed with a biophysical profile, not an NST.
2. Health teaching that the nurse would provide for parents of an immunosuppressed
child focuses on which important measure?
a. Nutrition
b. Pain control
c. Hand washing
d. Restricted visiting hours
Answer: c. Hand washing
Rationale: Hand hygiene is the most effective method to prevent infection in
immunocompromised children. Parents and caregivers must wash hands frequently to
reduce transmission of pathogens. While nutrition, pain control, and restricted visits
are important, infection prevention through hand washing is the primary teaching
point.
,3. Parents ask the nurse why their premature infant is receiving a feeding through the
mouth rather than the nose. What is the best explanation?
a. It is equally acceptable to use either insertion site.
b. Orogastric tube insertion can cause inflammation and obstruction of the nares
c. Newborns are obligate nose breathers so nasogastric may obstruct their breathing
d. Nasogastric tubes decrease the possibility of striking the vagal nerve
Answer: c. Newborns are obligate nose breathers so nasogastric may obstruct their
breathing
Rationale: Premature newborns primarily breathe through their noses. Nasogastric
tubes can block the nasal passage, causing respiratory distress. Orogastric tubes allow
safe feeding without compromising airway patency.
4. The school nurse is observing a child in the classroom. The child is speaking, then
suddenly stops and stares for about 5 seconds, and then continues speaking. The
nurse charts this experience as what type of seizure?
a. Tonic-clonic
b. Febrile
c. Absence
d. Partial (focal) seizure
Answer: c. Absence
Rationale: Absence seizures are characterized by brief lapses in consciousness, often
lasting 5–10 seconds, without postictal confusion. The child may stop speaking or
staring blankly. Tonic-clonic seizures involve convulsions, febrile seizures are triggered
by fever, and partial seizures affect one area of the brain.
5. A nurse in an emergency situation is caring for a child with a superficial burn of the
foot. Which of the following is the immediate priority?
,a. Decrease anxiety about procedures
b. Maintaining adequate circulatory function
c. Relieving pain and discomfort
d. Reassuring the child that all will be fine
Answer: c. Relieving pain and discomfort
Rationale: Pain control is the priority in superficial burns as it prevents shock,
reduces stress response, and improves cooperation with care. Circulatory function is
important in deeper burns, but in superficial burns, pain management is immediate.
Psychological reassurance is supportive but secondary.
6. A newborn is diagnosed with coarctation of the aorta. Which assessment should the
nurse make when caring for this infant?
a. Observing for excessive crying
b. Auscultating for a cardiac murmur
c. Assessing femoral and radial pulses simultaneously
d. Recording an upper extremity blood pressure
Answer: c. Assessing femoral and radial pulses simultaneously
Rationale: Coarctation of the aorta causes a narrowing of the aorta, leading to
weaker femoral pulses compared to radial pulses. Simultaneous pulse assessment
helps detect this discrepancy. Murmurs may be present, but pulse comparison is more
diagnostic.
7. An emergency department nurse is assessing a client after a fall. On assessment
the nurse notes swelling to the lateral aspect of the left ankle, point tenderness, and
crepitus on palpation. The nurse plans care for the client recognizing that this
presentation is most consistent with which injury?
a. Sprain
b. Fracture
c. Compartment syndrome
d. Muscle strain
, Answer: b. Fracture
Rationale: Crepitus, swelling, and point tenderness are classic signs of bone fracture.
Sprains involve ligaments and typically lack crepitus. Compartment syndrome is a
complication and involves pain out of proportion. Muscle strain causes tenderness but
not bony crepitus.
8. A 2-year-old is diagnosed with osteomyelitis. Which of the following would you
anticipate as a primary nursing intervention?
a. Maintaining intravenous antibiotic therapy
b. Keeping the child quiet while in skeletal traction
c. Restricting fluids to encourage red cell production
d. Assisting the child with crutch walking
Answer: a. Maintaining intravenous antibiotic therapy
Rationale: Osteomyelitis is a bacterial infection of the bone requiring IV antibiotics for
several weeks. Skeletal traction is not standard unless fracture exists. Fluid restriction
is unnecessary, and crutch walking is not indicated in a 2-year-old.
9. The nurse visits the foster home of a newborn with failure to thrive syndrome.
Which observation indicates a successful outcome for the child’s care?
a. Birth mother has stopped visiting the child
b. Birth father comes by the home to bring toys
c. Child eagerly takes a bottle and is gaining weight
d. Child is crying and has bruises over the lower legs
Answer: c. Child eagerly takes a bottle and is gaining weight
Rationale: Positive weight gain and eagerness to feed are primary indicators of
improvement in failure to thrive. Supervised visitation and toys do not directly indicate
health improvement. Signs of bruising indicate neglect and poor outcome.