NUR 2513 / NUR2513 Final Exam
Maternal Child Nursing – Rasmussen
| Advanced NCLEX-Level | Detailed Rationales
Q1.
A nurse is assessing a client at 34 weeks’ gestation who presents with sudden onset of painless,
bright red vaginal bleeding. The client denies abdominal pain. Vital signs are stable, and fetal
heart rate is within normal limits.
Which condition should the nurse suspect first?
A. Placental abruption
B. Placenta previa
C. Uterine rupture
D. Preterm labor
Answer: B. Placenta previa
Rationale:
Placenta previa classically presents with:
Painless vaginal bleeding
Bright red blood
No uterine tenderness
Placental abruption, in contrast, presents with painful bleeding and a firm uterus.
Q2.
A nurse is educating a pregnant client about daily fetal movement (kick) counts. Which
statement indicates correct understanding?
A. “I should feel at least 10 movements within 2 hours.”
B. “I only need to check movements once a week.”
C. “Movement decreases after 32 weeks.”
D. “I should count only when I feel contractions.”
Answer: A.
,Rationale:
Normal fetal well-being is indicated by ≥10 movements in 2 hours. Decreased movement may
signal fetal distress.
Q3.
A nurse is assessing a client suspected of preeclampsia. Which findings support this diagnosis?
A. Blood pressure 150/95 mmHg
B. Proteinuria
C. Generalized edema
D. Blood glucose 60 mg/dL
E. Visual disturbances
Answer: A, B, C, E
Rationale:
Preeclampsia includes:
Hypertension
Proteinuria
Edema
Neurologic symptoms (visual disturbances)
Hypoglycemia is unrelated.
Q4.
A postpartum client (2 hours after delivery) has heavy vaginal bleeding. On assessment, the
uterus is boggy and displaced to the right.
What is the nurse’s priority action?
A. Administer oxytocin
B. Massage the fundus
C. Assist client to void
D. Call the provider
Answer: B. Massage the fundus
Rationale:
A boggy uterus = uterine atony → risk of hemorrhage
FIRST action: fundal massage
,Then:
Empty bladder
Administer uterotonics if needed
Q5.
A nurse is assessing a newborn 10 minutes after birth. Which finding requires immediate
intervention?
A. Heart rate 145 bpm
B. Respiratory rate 58/min
C. Grunting with nasal flaring
D. Acrocyanosis
Answer: C.
Rationale:
Grunting + nasal flaring = respiratory distress → priority airway issue
Q6.
Which hormone is primarily responsible for maintaining pregnancy by suppressing uterine
contractions?
A. Estrogen
B. Progesterone
C. Oxytocin
D. Prolactin
Answer: B. Progesterone
Rationale:
Progesterone:
Maintains uterine lining
Prevents premature contractions
Q7.
A nurse is evaluating a client for true labor. Which finding confirms the diagnosis?
A. Irregular contractions
B. Cervical dilation and effacement
, C. Pain relieved with rest
D. Contractions that decrease with hydration
Answer: B.
Rationale:
True labor = progressive cervical change
False labor does NOT cause dilation.
Q8.
A newborn has an Apgar score of 6 at 1 minute. What is the nurse’s priority action?
A. Begin chest compressions
B. Provide supplemental oxygen
C. Continue routine care
D. Delay interventions until 5 minutes
Answer: B.
Rationale:
Score 4–6 = moderate distress → support oxygenation
Q9.
Which client is at highest risk for gestational diabetes mellitus (GDM)?
A. 20-year-old with BMI 19
B. First pregnancy, no history
C. Family history of diabetes
D. Regular exercise routine
Answer: C.
Rationale:
Major risk factors:
Family history
Obesity
Previous macrosomic infant
Q10.
A nurse is teaching a client about effective breastfeeding technique. Which statement indicates
understanding?
Maternal Child Nursing – Rasmussen
| Advanced NCLEX-Level | Detailed Rationales
Q1.
A nurse is assessing a client at 34 weeks’ gestation who presents with sudden onset of painless,
bright red vaginal bleeding. The client denies abdominal pain. Vital signs are stable, and fetal
heart rate is within normal limits.
Which condition should the nurse suspect first?
A. Placental abruption
B. Placenta previa
C. Uterine rupture
D. Preterm labor
Answer: B. Placenta previa
Rationale:
Placenta previa classically presents with:
Painless vaginal bleeding
Bright red blood
No uterine tenderness
Placental abruption, in contrast, presents with painful bleeding and a firm uterus.
Q2.
A nurse is educating a pregnant client about daily fetal movement (kick) counts. Which
statement indicates correct understanding?
A. “I should feel at least 10 movements within 2 hours.”
B. “I only need to check movements once a week.”
C. “Movement decreases after 32 weeks.”
D. “I should count only when I feel contractions.”
Answer: A.
,Rationale:
Normal fetal well-being is indicated by ≥10 movements in 2 hours. Decreased movement may
signal fetal distress.
Q3.
A nurse is assessing a client suspected of preeclampsia. Which findings support this diagnosis?
A. Blood pressure 150/95 mmHg
B. Proteinuria
C. Generalized edema
D. Blood glucose 60 mg/dL
E. Visual disturbances
Answer: A, B, C, E
Rationale:
Preeclampsia includes:
Hypertension
Proteinuria
Edema
Neurologic symptoms (visual disturbances)
Hypoglycemia is unrelated.
Q4.
A postpartum client (2 hours after delivery) has heavy vaginal bleeding. On assessment, the
uterus is boggy and displaced to the right.
What is the nurse’s priority action?
A. Administer oxytocin
B. Massage the fundus
C. Assist client to void
D. Call the provider
Answer: B. Massage the fundus
Rationale:
A boggy uterus = uterine atony → risk of hemorrhage
FIRST action: fundal massage
,Then:
Empty bladder
Administer uterotonics if needed
Q5.
A nurse is assessing a newborn 10 minutes after birth. Which finding requires immediate
intervention?
A. Heart rate 145 bpm
B. Respiratory rate 58/min
C. Grunting with nasal flaring
D. Acrocyanosis
Answer: C.
Rationale:
Grunting + nasal flaring = respiratory distress → priority airway issue
Q6.
Which hormone is primarily responsible for maintaining pregnancy by suppressing uterine
contractions?
A. Estrogen
B. Progesterone
C. Oxytocin
D. Prolactin
Answer: B. Progesterone
Rationale:
Progesterone:
Maintains uterine lining
Prevents premature contractions
Q7.
A nurse is evaluating a client for true labor. Which finding confirms the diagnosis?
A. Irregular contractions
B. Cervical dilation and effacement
, C. Pain relieved with rest
D. Contractions that decrease with hydration
Answer: B.
Rationale:
True labor = progressive cervical change
False labor does NOT cause dilation.
Q8.
A newborn has an Apgar score of 6 at 1 minute. What is the nurse’s priority action?
A. Begin chest compressions
B. Provide supplemental oxygen
C. Continue routine care
D. Delay interventions until 5 minutes
Answer: B.
Rationale:
Score 4–6 = moderate distress → support oxygenation
Q9.
Which client is at highest risk for gestational diabetes mellitus (GDM)?
A. 20-year-old with BMI 19
B. First pregnancy, no history
C. Family history of diabetes
D. Regular exercise routine
Answer: C.
Rationale:
Major risk factors:
Family history
Obesity
Previous macrosomic infant
Q10.
A nurse is teaching a client about effective breastfeeding technique. Which statement indicates
understanding?
