NUR 254 Exam 2: Maternal and Pediatrics - Galen College
of Nursing Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is assessing a client who is at 34 weeks of gestation and has a prescription for magnesium sulfate.
Which of the following findings should the nurse identify as a manifestation of magnesium toxicity?
A. Increased urine output
B. Respiratory rate of 10/min
C. Hyperreflexia
D. Tachycardia
Correct Answer: B
Rationale: Magnesium sulfate is used to prevent seizures in preeclampsia but can lead to toxicity. A
respiratory rate below 12/min is a primary indicator of central nervous system depression caused by
high magnesium levels. The nurse must also monitor for the loss of deep tendon reflexes and decreased
urinary output. If these signs occur, the infusion should be discontinued immediately to prevent cardiac
arrest. Calcium gluconate is kept at the bedside as the specific antidote for magnesium toxicity.
2. A nurse is caring for a client in the first stage of labor and notes late decelerations on the fetal heart rate
monitor. Which of the following actions should the nurse take first?
A. Perform a vaginal exam
B. Administer oxygen via face mask
C. Increase the IV fluid rate
D. Turn the client to a side-lying position
Correct Answer: D
,Rationale: Late decelerations are indicative of uteroplacental insufficiency and require immediate
nursing intervention. The first action should be to improve placental perfusion by repositioning the client
to her side. This position relieves pressure on the vena cava and enhances blood flow to the uterus. While
oxygen and IV fluids are also important, repositioning is the most immediate and simple corrective
action. The nurse must continue to monitor the fetal heart rate for improvement after this intervention.
3. A client is at 20 weeks of gestation and asks about the purpose of an alpha-fetoprotein (AFP) screening.
Which of the following statements is appropriate for the nurse to make?
A. It determines the gender of the baby.
B. It assesses the lung maturity of the fetus.
C. It identifies the presence of gestational diabetes.
D. It checks for neural tube defects or chromosomal abnormalities.
Correct Answer: D
Rationale: AFP is a protein produced by the fetal liver and is measured in maternal blood. High levels of
AFP may indicate a neural tube defect such as spina bifida. Conversely, low levels of AFP can be
associated with chromosomal disorders like Down syndrome. This test is a screening tool rather than a
diagnostic one and usually occurs between 15 and 22 weeks. Abnormal results require further diagnostic
testing such as an ultrasound or amniocentesis.
4. A postpartum nurse is assessing a client 2 hours after delivery and notes that the fundus is boggy and
displaced to the right. Which of the following actions should the nurse take?
A. Assist the client to empty her bladder
B. Massage the fundus until firm
C. Administer oxytocin intramuscularly
, D. Notify the provider immediately
Correct Answer: A
Rationale: A fundus that is displaced from the midline usually indicates that the bladder is full and
pushing the uterus up. A full bladder prevents the uterus from contracting effectively, which increases
the risk of postpartum hemorrhage. Assisting the client to void is the priority intervention to allow the
uterus to return to the midline and contract. If the fundus remains boggy after voiding, then fundal
massage would be the next step. Nurses must monitor bladder distention closely during the early
postpartum period.
5. A nurse is caring for a 4-year-old child with suspected epiglottitis. Which of the following nursing actions
is contraindicated?
A. Placing the child in an upright position
B. Using a tongue blade to inspect the throat
C. Preparing for emergency intubation
D. Monitoring oxygen saturation levels
Correct Answer: B
Rationale: Epiglottitis is a medical emergency that can lead to rapid airway obstruction in children.
Inspecting the throat with a tongue blade or swab can trigger a laryngospasm and completely block the
airway. The child should be allowed to remain in a position of comfort, usually sitting upright or in a
‘tripod’ position. Emergency equipment for intubation or tracheostomy must be available at the bedside
at all times. The focus of care is maintaining a patent airway and reducing the child’s anxiety.
of Nursing Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is assessing a client who is at 34 weeks of gestation and has a prescription for magnesium sulfate.
Which of the following findings should the nurse identify as a manifestation of magnesium toxicity?
A. Increased urine output
B. Respiratory rate of 10/min
C. Hyperreflexia
D. Tachycardia
Correct Answer: B
Rationale: Magnesium sulfate is used to prevent seizures in preeclampsia but can lead to toxicity. A
respiratory rate below 12/min is a primary indicator of central nervous system depression caused by
high magnesium levels. The nurse must also monitor for the loss of deep tendon reflexes and decreased
urinary output. If these signs occur, the infusion should be discontinued immediately to prevent cardiac
arrest. Calcium gluconate is kept at the bedside as the specific antidote for magnesium toxicity.
2. A nurse is caring for a client in the first stage of labor and notes late decelerations on the fetal heart rate
monitor. Which of the following actions should the nurse take first?
A. Perform a vaginal exam
B. Administer oxygen via face mask
C. Increase the IV fluid rate
D. Turn the client to a side-lying position
Correct Answer: D
,Rationale: Late decelerations are indicative of uteroplacental insufficiency and require immediate
nursing intervention. The first action should be to improve placental perfusion by repositioning the client
to her side. This position relieves pressure on the vena cava and enhances blood flow to the uterus. While
oxygen and IV fluids are also important, repositioning is the most immediate and simple corrective
action. The nurse must continue to monitor the fetal heart rate for improvement after this intervention.
3. A client is at 20 weeks of gestation and asks about the purpose of an alpha-fetoprotein (AFP) screening.
Which of the following statements is appropriate for the nurse to make?
A. It determines the gender of the baby.
B. It assesses the lung maturity of the fetus.
C. It identifies the presence of gestational diabetes.
D. It checks for neural tube defects or chromosomal abnormalities.
Correct Answer: D
Rationale: AFP is a protein produced by the fetal liver and is measured in maternal blood. High levels of
AFP may indicate a neural tube defect such as spina bifida. Conversely, low levels of AFP can be
associated with chromosomal disorders like Down syndrome. This test is a screening tool rather than a
diagnostic one and usually occurs between 15 and 22 weeks. Abnormal results require further diagnostic
testing such as an ultrasound or amniocentesis.
4. A postpartum nurse is assessing a client 2 hours after delivery and notes that the fundus is boggy and
displaced to the right. Which of the following actions should the nurse take?
A. Assist the client to empty her bladder
B. Massage the fundus until firm
C. Administer oxytocin intramuscularly
, D. Notify the provider immediately
Correct Answer: A
Rationale: A fundus that is displaced from the midline usually indicates that the bladder is full and
pushing the uterus up. A full bladder prevents the uterus from contracting effectively, which increases
the risk of postpartum hemorrhage. Assisting the client to void is the priority intervention to allow the
uterus to return to the midline and contract. If the fundus remains boggy after voiding, then fundal
massage would be the next step. Nurses must monitor bladder distention closely during the early
postpartum period.
5. A nurse is caring for a 4-year-old child with suspected epiglottitis. Which of the following nursing actions
is contraindicated?
A. Placing the child in an upright position
B. Using a tongue blade to inspect the throat
C. Preparing for emergency intubation
D. Monitoring oxygen saturation levels
Correct Answer: B
Rationale: Epiglottitis is a medical emergency that can lead to rapid airway obstruction in children.
Inspecting the throat with a tongue blade or swab can trigger a laryngospasm and completely block the
airway. The child should be allowed to remain in a position of comfort, usually sitting upright or in a
‘tripod’ position. Emergency equipment for intubation or tracheostomy must be available at the bedside
at all times. The focus of care is maintaining a patent airway and reducing the child’s anxiety.
