NUR2513/NUR 2513 Exam 4 V3 | Maternal-
Child Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is assessing a postpartum client 2 hours after delivery and finds the fundus is boggy
and displaced to the right. Which action should the nurse take first?
A. Encourage the client to void
B. Administer oxytocin as prescribed
C. Massage the fundus until firm
D. Notify the healthcare provider immediately
Correct Answer: A
Rationale: A displaced fundus to the right is most commonly caused by a distended
bladder, which pushes the uterus out of position and prevents effective contraction.
Encouraging the client to void or catheterizing the client will allow the uterus to return to
the midline and contract properly. This intervention addresses the root cause of the
displacement and helps prevent postpartum hemorrhage.
2. A newborn is diagnosed with hyperbilirubinemia and is placed under phototherapy. Which
nursing intervention is essential for this infant?
A. Cover the infant’s eyes with opaque patches
B. Apply lotion to the skin to prevent drying
,C. Limit fluid intake to prevent diarrhea
D. Keep the infant in a prone position
Correct Answer: A
Rationale: The infant’s eyes must be protected from the high-intensity light used in
phototherapy to prevent retinal damage. The patches should be removed during feedings
so the nurse can assess the eyes and allow for bonding. The infant’s temperature and
hydration status must also be monitored closely during this treatment.
3. A 4-week-old infant is brought to the clinic with reports of projectile vomiting after
feedings. The nurse notes a palpable olive-shaped mass in the epigastrium. Which condition
does the nurse suspect?
A. Gastroesophageal reflux
B. Intussusception
C. Pyloric stenosis
D. Hirschsprung disease
Correct Answer: C
Rationale: Hypertrophic pyloric stenosis is characterized by the thickening of the pyloric
sphincter, leading to gastric outlet obstruction. The classic clinical manifestations include
non-bilious projectile vomiting and a palpable olive-shaped mass in the right upper
quadrant. Surgical repair, known as a pyloromyotomy, is the definitive treatment for this
condition.
, 4. The nurse is caring for a child with suspected intussusception. Which finding should the
nurse expect to observe?
A. Currant jelly-like stools
B. Ribbon-like stools
C. Steatorrhea
D. Projectile vomiting
Correct Answer: A
Rationale: Intussusception occurs when one portion of the intestine telescopes into
another, causing obstruction and ischemia. This leads to the classic sign of ‘currant jelly’
stools, which contain a mixture of blood and mucus. Other signs include sudden onset of
abdominal pain, a sausage-shaped abdominal mass, and screaming with legs drawn up.
5. An infant is admitted with Respiratory Syncytial Virus (RSV) and bronchiolitis. Which type
of precautions should the nurse implement?
A. Airborne precautions
B. Droplet precautions
C. Contact precautions
D. Protective environment
Correct Answer: C
Child Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is assessing a postpartum client 2 hours after delivery and finds the fundus is boggy
and displaced to the right. Which action should the nurse take first?
A. Encourage the client to void
B. Administer oxytocin as prescribed
C. Massage the fundus until firm
D. Notify the healthcare provider immediately
Correct Answer: A
Rationale: A displaced fundus to the right is most commonly caused by a distended
bladder, which pushes the uterus out of position and prevents effective contraction.
Encouraging the client to void or catheterizing the client will allow the uterus to return to
the midline and contract properly. This intervention addresses the root cause of the
displacement and helps prevent postpartum hemorrhage.
2. A newborn is diagnosed with hyperbilirubinemia and is placed under phototherapy. Which
nursing intervention is essential for this infant?
A. Cover the infant’s eyes with opaque patches
B. Apply lotion to the skin to prevent drying
,C. Limit fluid intake to prevent diarrhea
D. Keep the infant in a prone position
Correct Answer: A
Rationale: The infant’s eyes must be protected from the high-intensity light used in
phototherapy to prevent retinal damage. The patches should be removed during feedings
so the nurse can assess the eyes and allow for bonding. The infant’s temperature and
hydration status must also be monitored closely during this treatment.
3. A 4-week-old infant is brought to the clinic with reports of projectile vomiting after
feedings. The nurse notes a palpable olive-shaped mass in the epigastrium. Which condition
does the nurse suspect?
A. Gastroesophageal reflux
B. Intussusception
C. Pyloric stenosis
D. Hirschsprung disease
Correct Answer: C
Rationale: Hypertrophic pyloric stenosis is characterized by the thickening of the pyloric
sphincter, leading to gastric outlet obstruction. The classic clinical manifestations include
non-bilious projectile vomiting and a palpable olive-shaped mass in the right upper
quadrant. Surgical repair, known as a pyloromyotomy, is the definitive treatment for this
condition.
, 4. The nurse is caring for a child with suspected intussusception. Which finding should the
nurse expect to observe?
A. Currant jelly-like stools
B. Ribbon-like stools
C. Steatorrhea
D. Projectile vomiting
Correct Answer: A
Rationale: Intussusception occurs when one portion of the intestine telescopes into
another, causing obstruction and ischemia. This leads to the classic sign of ‘currant jelly’
stools, which contain a mixture of blood and mucus. Other signs include sudden onset of
abdominal pain, a sausage-shaped abdominal mass, and screaming with legs drawn up.
5. An infant is admitted with Respiratory Syncytial Virus (RSV) and bronchiolitis. Which type
of precautions should the nurse implement?
A. Airborne precautions
B. Droplet precautions
C. Contact precautions
D. Protective environment
Correct Answer: C
