NR327/NR 327 Exam 2 V2 | Maternal Child
Nursing Q&A with Rationale | Chamberlain
University
1. A nurse is caring for a client who is at 34 weeks of gestation and is receiving magnesium
sulfate for preeclampsia. Which of the following findings is the priority for the nurse to report
to the provider?
A. Urinary output of 40 mL/hr
B. Serum magnesium level of 6 mEq/L
C. Deep tendon reflexes of 2+
D. Respiratory rate of 10 breaths/min
Correct Answer: D
Rationale: A respiratory rate of less than 12 breaths per minute is a classic sign of
magnesium sulfate toxicity and requires immediate intervention. The nurse should stop the
infusion and notify the provider while preparing to administer calcium gluconate if
necessary. Other signs of toxicity include absent deep tendon reflexes and a significant
drop in urinary output below 30 mL/hr.
2. A nurse is assessing a client who is 2 hours postpartum and has a boggy fundus that is
displaced to the right of the midline. What is the nurse’s first action?
A. Perform fundal massage
,B. Administer oxytocin 10 units IM
C. Assist the client to the bathroom to void
D. Notify the provider immediately
Correct Answer: C
Rationale: A displaced fundus to the right is most commonly caused by a full bladder,
which prevents the uterus from contracting effectively. Assisting the client to void or
catheterizing the client will allow the uterus to return to the midline and contract. Once the
bladder is empty, the nurse should re-evaluate the fundus and perform massage if it
remains boggy.
3. A nurse is interpreting a fetal heart rate tracing and notes late decelerations. Which of the
following actions should the nurse take first?
A. Assist the client into a side-lying position
B. Apply oxygen at 10 L/min via nonrebreather mask
C. Increase the IV fluid rate
D. Prepare for an emergency cesarean birth
Correct Answer: A
Rationale: The first action for late decelerations is to improve uteroplacental perfusion by
repositioning the client to a side-lying (lateral) position. Late decelerations are caused by
uteroplacental insufficiency and require immediate nursing intervention to prevent fetal
,hypoxia. Subsequent actions include increasing IV fluids, administering oxygen, and
discontinuing any oxytocin infusions.
4. A client at 32 weeks of gestation is admitted for preterm labor. The provider orders
betamethasone 12 mg IM. What is the purpose of this medication?
A. To stop uterine contractions
B. To promote fetal lung maturity
C. To prevent neonatal group B streptococcus infection
D. To increase maternal blood volume
Correct Answer: B
Rationale: Betamethasone is a glucocorticoid administered to clients in preterm labor to
stimulate the production of surfactant in the fetal lungs. This helps reduce the risk of
respiratory distress syndrome (RDS) and other complications in the neonate after delivery.
It is typically given in two doses 24 hours apart when delivery is anticipated between 24
and 34 weeks of gestation.
5. A nurse is assessing a newborn 1 hour after birth. Which of the following findings should
the nurse report to the provider?
A. Acrocyanosis of the hands and feet
B. Respiratory rate of 48 breaths/min
C. Generalized petechiae on the trunk
, D. Axillary temperature of 36.8 C (98.2 F)
Correct Answer: C
Rationale: Generalized petechiae on the trunk is an abnormal finding and can indicate a
clotting factor deficiency or infection in the newborn. Acrocyanosis is a normal finding in
the first 24 to 48 hours as the peripheral circulation stabilizes. A respiratory rate of 30 to
60 breaths/min and a temperature within the normal range are expected findings for a
healthy newborn.
6. A nurse is educating a client who is 3 days postpartum and breastfeeding. The client
reports that her breasts are very firm, painful, and warm to the touch. Which intervention
should the nurse recommend?
A. Apply ice packs between feedings
B. Use cabbage leaves after feedings to reduce swelling
C. Avoid breastfeeding for 24 hours to let the breasts rest
D. Wear a tight-fitting bra continuously
Correct Answer: B
Rationale: Breast engorgement typically occurs 3 to 5 days postpartum and is caused by
increased blood flow and milk production. Applying cool cabbage leaves or cold
compresses can help reduce the inflammation and discomfort associated with
engorgement. Frequent breastfeeding and warm showers before nursing also help facilitate
milk let-down and relieve pressure.
Nursing Q&A with Rationale | Chamberlain
University
1. A nurse is caring for a client who is at 34 weeks of gestation and is receiving magnesium
sulfate for preeclampsia. Which of the following findings is the priority for the nurse to report
to the provider?
A. Urinary output of 40 mL/hr
B. Serum magnesium level of 6 mEq/L
C. Deep tendon reflexes of 2+
D. Respiratory rate of 10 breaths/min
Correct Answer: D
Rationale: A respiratory rate of less than 12 breaths per minute is a classic sign of
magnesium sulfate toxicity and requires immediate intervention. The nurse should stop the
infusion and notify the provider while preparing to administer calcium gluconate if
necessary. Other signs of toxicity include absent deep tendon reflexes and a significant
drop in urinary output below 30 mL/hr.
2. A nurse is assessing a client who is 2 hours postpartum and has a boggy fundus that is
displaced to the right of the midline. What is the nurse’s first action?
A. Perform fundal massage
,B. Administer oxytocin 10 units IM
C. Assist the client to the bathroom to void
D. Notify the provider immediately
Correct Answer: C
Rationale: A displaced fundus to the right is most commonly caused by a full bladder,
which prevents the uterus from contracting effectively. Assisting the client to void or
catheterizing the client will allow the uterus to return to the midline and contract. Once the
bladder is empty, the nurse should re-evaluate the fundus and perform massage if it
remains boggy.
3. A nurse is interpreting a fetal heart rate tracing and notes late decelerations. Which of the
following actions should the nurse take first?
A. Assist the client into a side-lying position
B. Apply oxygen at 10 L/min via nonrebreather mask
C. Increase the IV fluid rate
D. Prepare for an emergency cesarean birth
Correct Answer: A
Rationale: The first action for late decelerations is to improve uteroplacental perfusion by
repositioning the client to a side-lying (lateral) position. Late decelerations are caused by
uteroplacental insufficiency and require immediate nursing intervention to prevent fetal
,hypoxia. Subsequent actions include increasing IV fluids, administering oxygen, and
discontinuing any oxytocin infusions.
4. A client at 32 weeks of gestation is admitted for preterm labor. The provider orders
betamethasone 12 mg IM. What is the purpose of this medication?
A. To stop uterine contractions
B. To promote fetal lung maturity
C. To prevent neonatal group B streptococcus infection
D. To increase maternal blood volume
Correct Answer: B
Rationale: Betamethasone is a glucocorticoid administered to clients in preterm labor to
stimulate the production of surfactant in the fetal lungs. This helps reduce the risk of
respiratory distress syndrome (RDS) and other complications in the neonate after delivery.
It is typically given in two doses 24 hours apart when delivery is anticipated between 24
and 34 weeks of gestation.
5. A nurse is assessing a newborn 1 hour after birth. Which of the following findings should
the nurse report to the provider?
A. Acrocyanosis of the hands and feet
B. Respiratory rate of 48 breaths/min
C. Generalized petechiae on the trunk
, D. Axillary temperature of 36.8 C (98.2 F)
Correct Answer: C
Rationale: Generalized petechiae on the trunk is an abnormal finding and can indicate a
clotting factor deficiency or infection in the newborn. Acrocyanosis is a normal finding in
the first 24 to 48 hours as the peripheral circulation stabilizes. A respiratory rate of 30 to
60 breaths/min and a temperature within the normal range are expected findings for a
healthy newborn.
6. A nurse is educating a client who is 3 days postpartum and breastfeeding. The client
reports that her breasts are very firm, painful, and warm to the touch. Which intervention
should the nurse recommend?
A. Apply ice packs between feedings
B. Use cabbage leaves after feedings to reduce swelling
C. Avoid breastfeeding for 24 hours to let the breasts rest
D. Wear a tight-fitting bra continuously
Correct Answer: B
Rationale: Breast engorgement typically occurs 3 to 5 days postpartum and is caused by
increased blood flow and milk production. Applying cool cabbage leaves or cold
compresses can help reduce the inflammation and discomfort associated with
engorgement. Frequent breastfeeding and warm showers before nursing also help facilitate
milk let-down and relieve pressure.
