NUR2513/NUR 2513 Exam 4 V1 | Maternal
Child Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is assessing a postpartum client 2 hours after delivery and notes a boggy uterus
that is displaced to the right. Which of the following is the priority nursing action?
A. Massage the fundus firmly.
B. Administer oxytocin as prescribed.
C. Assist the client to empty her bladder.
D. Notify the healthcare provider immediately.
Correct Answer: C
Rationale: A uterus displaced to the right is a classic sign of bladder distention, which
prevents the uterus from contracting effectively. Assisting the client to void allows the
uterus to return to the midline and firm up naturally. This intervention addresses the root
cause of the displacement and helps prevent postpartum hemorrhage.
2. A nurse is caring for a client receiving magnesium sulfate for preeclampsia. Which of the
following findings should the nurse report as a sign of magnesium toxicity?
A. Deep tendon reflexes of +2.
B. Blood pressure of 150/90 mmHg.
C. Respiratory rate of 10 breaths per minute.
,D. Urinary output of 40 mL/hour.
Correct Answer: C
Rationale: Magnesium sulfate is a central nervous system depressant, and a respiratory
rate below 12 breaths per minute is a critical indicator of toxicity. The nurse must also
monitor for the loss of deep tendon reflexes and a significant drop in urinary output. If
toxicity is suspected, the infusion must be stopped and calcium gluconate should be
administered as the antidote.
3. Which of the following medications is routinely administered to newborns within 1 hour of
birth to prevent hemorrhagic disease?
A. Erythromycin ointment
B. Hepatitis B vaccine
C. Naloxone
D. Vitamin K (Phytonadione)
Correct Answer: D
Rationale: Newborns are born with low levels of Vitamin K because it does not cross the
placenta well and the sterile gut does not yet produce it. Vitamin K is essential for the
synthesis of clotting factors in the liver. Administering this intramuscularly shortly after
birth prevents Vitamin K Deficiency Bleeding (VKDB).
, 4. A 2-year-old child is brought to the emergency department with a ‘barking’ cough and
stridor. The nurse suspects croup. Which of the following is the initial nursing action?
A. Administer oral antibiotics.
B. Perform a throat culture.
C. Assess respiratory status and pulse oximetry.
D. Prepare for immediate intubation.
Correct Answer: C
Rationale: The initial action in any respiratory distress scenario is to assess the severity of
the airway obstruction and the patient’s oxygenation. A barking cough and inspiratory
stridor are characteristic of laryngotracheobronchitis (croup). Monitoring the respiratory
rate and oxygen saturation helps determine if the child requires cool mist or racemic
epinephrine.
5. A nurse is teaching a parent about sudden infant death syndrome (SIDS) prevention. Which
of the following statements by the parent indicates an understanding of the teaching?
A. I will place my baby on their side to sleep.
B. I will keep soft pillows and blankets in the crib.
C. I will place my baby on their back to sleep.
D. I will keep the room very warm so the baby doesn’t get cold.
Correct Answer: C
Child Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is assessing a postpartum client 2 hours after delivery and notes a boggy uterus
that is displaced to the right. Which of the following is the priority nursing action?
A. Massage the fundus firmly.
B. Administer oxytocin as prescribed.
C. Assist the client to empty her bladder.
D. Notify the healthcare provider immediately.
Correct Answer: C
Rationale: A uterus displaced to the right is a classic sign of bladder distention, which
prevents the uterus from contracting effectively. Assisting the client to void allows the
uterus to return to the midline and firm up naturally. This intervention addresses the root
cause of the displacement and helps prevent postpartum hemorrhage.
2. A nurse is caring for a client receiving magnesium sulfate for preeclampsia. Which of the
following findings should the nurse report as a sign of magnesium toxicity?
A. Deep tendon reflexes of +2.
B. Blood pressure of 150/90 mmHg.
C. Respiratory rate of 10 breaths per minute.
,D. Urinary output of 40 mL/hour.
Correct Answer: C
Rationale: Magnesium sulfate is a central nervous system depressant, and a respiratory
rate below 12 breaths per minute is a critical indicator of toxicity. The nurse must also
monitor for the loss of deep tendon reflexes and a significant drop in urinary output. If
toxicity is suspected, the infusion must be stopped and calcium gluconate should be
administered as the antidote.
3. Which of the following medications is routinely administered to newborns within 1 hour of
birth to prevent hemorrhagic disease?
A. Erythromycin ointment
B. Hepatitis B vaccine
C. Naloxone
D. Vitamin K (Phytonadione)
Correct Answer: D
Rationale: Newborns are born with low levels of Vitamin K because it does not cross the
placenta well and the sterile gut does not yet produce it. Vitamin K is essential for the
synthesis of clotting factors in the liver. Administering this intramuscularly shortly after
birth prevents Vitamin K Deficiency Bleeding (VKDB).
, 4. A 2-year-old child is brought to the emergency department with a ‘barking’ cough and
stridor. The nurse suspects croup. Which of the following is the initial nursing action?
A. Administer oral antibiotics.
B. Perform a throat culture.
C. Assess respiratory status and pulse oximetry.
D. Prepare for immediate intubation.
Correct Answer: C
Rationale: The initial action in any respiratory distress scenario is to assess the severity of
the airway obstruction and the patient’s oxygenation. A barking cough and inspiratory
stridor are characteristic of laryngotracheobronchitis (croup). Monitoring the respiratory
rate and oxygen saturation helps determine if the child requires cool mist or racemic
epinephrine.
5. A nurse is teaching a parent about sudden infant death syndrome (SIDS) prevention. Which
of the following statements by the parent indicates an understanding of the teaching?
A. I will place my baby on their side to sleep.
B. I will keep soft pillows and blankets in the crib.
C. I will place my baby on their back to sleep.
D. I will keep the room very warm so the baby doesn’t get cold.
Correct Answer: C
