NUR 2513 Exam 2 | Maternal Child Nursing | Rasmussen University 75 Questions | 75 Minutes
NUR 2513 / NUR2513 Exam 2 (Latest ):
Maternal Child Nursing - Rasmussen
Questions and Verified Answers | 100% Correct | Modules 3-5
Rasmussen University | 75 Questions | 75 Minutes | 2026-2027 Curriculum Standards
Section 1: Labor and Birth (Q1-Q25)
Stages of Labor, Cervical Assessment, Induction of Labor, FHR Monitoring, Labor Complications
Q1: A nurse is caring for a client in the active phase of the first stage of labor. The client is 7 cm dilated, 90% effaced, and
the fetus is at +1 station. Which of the following findings should the nurse expect during this phase?
A. Contractions occur every 2-3 minutes, lasting 60-90 seconds, and are moderate to strong in intensity **[CORRECT]**
B. The client reports an urge to push and rectal pressure is present
C. Contractions occur every 5-6 minutes, lasting 30-40 seconds, and are mild in intensity
D. The placenta is delivered and the fundus is firm at midline
Correct Answer: A
Rationale: The active phase of the first stage is characterized by cervical dilation from 4-7 cm with contractions every 2-3 minutes, lasting
60-90 seconds, and moderate to strong intensity. Option B describes the transition phase or second stage with the urge to push. Option C
describes the latent phase with mild contractions. Option D describes the third stage involving placental delivery, not the active phase of the first
stage.
Q2: A nurse performs a sterile vaginal exam and notes the cervix is 5 cm dilated, 50% effaced, and the presenting part is at -2
station. The nurse correctly identifies the presenting part is located at which position?
A. 2 cm above the ischial spines **[CORRECT]**
B. 2 cm below the ischial spines
C. At the level of the ischial spines
D. 5 cm above the ischial spines
Correct Answer: A
Rationale: Station describes the relationship of the presenting part to the ischial spines. Negative stations (-3 to -1) indicate the presenting part is
above the ischial spines. At -2 station, the presenting part is 2 cm above the ischial spines. Station 0 means at the level of the ischial spines, and
positive stations (+1 to +3) indicate below. This is a fundamental Rasmussen NUR 2513 cervical assessment concept.
Q3: A nurse is caring for a client receiving oxytocin for induction of labor. The nurse notes contractions every 90 seconds
with less than 30 seconds of rest between contractions. Which is the priority nursing action?
A. Increase the oxytocin infusion rate to progress labor
B. Stop the oxytocin infusion and reposition the client on her left side **[CORRECT]**
C. Administer terbutaline subcutaneously
D. Prepare the client for an amniotomy
Correct Answer: B
Rationale: Contractions every 90 seconds with less than 30 seconds of rest indicate uterine hyperstimulation (tachysystole). The priority action is
to stop the oxytocin infusion immediately and reposition the client on her left side to improve uteroplacental perfusion. Increasing oxytocin
worsens hyperstimulation. Terbutaline may be needed if conservative measures fail, but stopping oxytocin and repositioning come first per
Rasmussen NUR 2513 protocol.
Q4: A nurse reviews the FHR tracing and observes decelerations that mirror the shape of the contraction, with the nadir
occurring at the same time as the peak of the contraction. The nurse identifies these as which type?
A. Variable decelerations
B. Prolonged decelerations
C. Early decelerations **[CORRECT]**
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,NUR 2513 Exam 2 | Maternal Child Nursing | Rasmussen University 75 Questions | 75 Minutes
D. Late decelerations
Correct Answer: C
Rationale: Early decelerations are caused by fetal head compression during contractions and have a uniform mirror-image shape with nadir at
the peak of the contraction. They are benign and require no intervention. Variable decelerations from cord compression have abrupt onset and
variable shape. Late decelerations from uteroplacental insufficiency have the nadir after the peak, an ominous sign requiring prompt
intervention.
Q5: A nurse monitors a client in labor and observes late decelerations on the FHR tracing. Which nursing intervention should
the nurse implement first?
A. Apply a fetal scalp electrode for more accurate monitoring
B. Reposition the client to the left lateral position and administer oxygen via face mask **[CORRECT]**
C. Prepare the client for an emergency cesarean delivery
D. Increase the IV fluid rate to 200 mL/hr
Correct Answer: B
Rationale: Late decelerations indicate uteroplacental insufficiency. The first priority interventions are intrauterine resuscitation: reposition the
client to the left lateral side to improve blood flow and administer oxygen at 8-10 L/min via face mask to maximize fetal oxygenation. C-section
may eventually be needed, but initial measures should correct the insufficiency first. A fetal scalp electrode does not address the cause.
Q6: A nurse is caring for a laboring client whose FHR tracing shows variable decelerations with moderate variability. Which
is the most likely cause of variable decelerations?
A. Fetal head compression
B. Uteroplacental insufficiency
C. Umbilical cord compression **[CORRECT]**
D. Fetal hypoxia
Correct Answer: C
Rationale: Variable decelerations are caused by compression of the umbilical cord, transiently reducing blood flow and oxygen to the fetus.
They have abrupt onset and recovery with variable shape and timing. Initial interventions include repositioning, amnioinfusion if membranes
are ruptured, and discontinuing oxytocin. Head compression causes early decelerations; uteroplacental insufficiency causes late decelerations.
Q7: A nurse assesses the FHR tracing and notes a baseline of 145 bpm with moderate variability (amplitude 12 bpm). No
decelerations are present. Two spontaneous accelerations of 15 bpm above baseline are noted, each lasting 15 seconds. The
nurse interprets this tracing as which category?
A. Category I - reassuring FHR pattern **[CORRECT]**
B. Category II - indeterminate FHR pattern
C. Category III - abnormal FHR pattern
D. Non-reassuring FHR pattern requiring immediate intervention
Correct Answer: A
Rationale: This tracing meets all Category I criteria: normal baseline (110-160 bpm), moderate variability (6-25 bpm), accelerations present,
and absence of late or variable decelerations. Category I patterns are strongly associated with normal fetal acid-base status and require no
intervention. Category II is indeterminate requiring evaluation. Category III is abnormal requiring prompt intervention.
Q8: A client at 39 weeks gestation is being prepared for induction of labor due to gestational hypertension. Which is a
required pre-induction assessment?
A. Performing a biophysical profile to assess amniotic fluid volume only
B. Assessing cervical readiness (Bishop score) and confirming fetal presentation and engagement **[CORRECT]**
C. Obtaining a STAT CBC to rule out maternal anemia
D. Performing a contraction stress test to confirm fetal well-being
Correct Answer: B
Rationale: Before induction, the nurse must assess cervical readiness using the Bishop score (dilation, effacement, station, consistency, position).
A score of 8+ indicates high likelihood of successful induction. Fetal presentation and engagement must also be confirmed, as induction with
unengaged presenting part increases cord prolapse risk. Biophysical profile, CBC, and contraction stress test are not routine pre-induction
Page 2
, NUR 2513 Exam 2 | Maternal Child Nursing | Rasmussen University 75 Questions | 75 Minutes
requirements per Rasmussen NUR 2513.
Q9: A nurse cares for a client in the transition phase at 9 cm dilation who reports intense pressure and the urge to push.
Which nursing response is most appropriate?
A. Encourage the client to bear down with each contraction
B. Instruct the client to breathe through the urge to push using pant-blow breathing **[CORRECT]**
C. Administer butorphanol as prescribed for pain management
D. Prepare the client for immediate vacuum-assisted delivery
Correct Answer: B
Rationale: During transition (8-10 cm), the client often feels a strong urge to push, but pushing before full dilation (10 cm) can cause cervical
edema and lacerations. The nurse should instruct the client to pant-blow through contractions to resist pushing until complete dilation. Bearing
down is contraindicated. Opioids are avoided this close to delivery. Vacuum delivery is for the second stage, not transition.
Q10: A nurse monitors a client receiving magnesium sulfate for preeclampsia. Which finding indicates magnesium toxicity?
A. Respiratory rate of 18 breaths/min, DTRs 2+, urinary output 40 mL/hr
B. Respiratory rate of 10 breaths/min, absent DTRs, urinary output 20 mL/hr **[CORRECT]**
C. Blood pressure 150/90 mmHg, headache, visual disturbances
D. Heart rate 110 bpm, flushing, feeling of warmth
Correct Answer: B
Rationale: Magnesium toxicity is indicated by respiratory depression (rate below 12/min), loss of deep tendon reflexes, and oliguria (below 30
mL/hr). These cardinal signs require calcium gluconate as the antidote. Option A shows normal findings. Option C describes preeclampsia
itself. Option D describes common non-toxic side effects of magnesium sulfate therapy.
Q11: A client at 35 weeks presents with sudden onset of severe abdominal pain and dark red vaginal bleeding. The uterus is
firm and board-like. The nurse should prepare the client for which of the following?
A. Immediate cesarean delivery for placenta previa
B. Expectant management with bed rest and pelvic rest
C. Emergency delivery for placental abruption **[CORRECT]**
D. Administration of oxytocin to augment labor
Correct Answer: C
Rationale: The classic triad of placental abruption is sudden severe abdominal pain with dark red bleeding and a firm, board-like uterus from
tetanic contractions. This obstetric emergency requires immediate delivery, usually via emergency C-section. Placenta previa presents with
painless bright red bleeding and soft uterus. Expectant management is inappropriate for acute abruption. Oxytocin is contraindicated in
abruption.
Q12: A client at 32 weeks is diagnosed with placenta previa covering the internal cervical os. The client reports bright red
vaginal bleeding. Which nursing action is contraindicated?
A. Assessing vital signs and fetal heart rate every 15 minutes
B. Performing a sterile vaginal examination to assess cervical dilation **[CORRECT]**
C. Placing the client on bed rest in a side-lying position
D. Initiating IV access with a large-bore catheter
Correct Answer: B
Rationale: In placenta previa, vaginal examinations are absolutely contraindicated because they can disrupt the placenta and cause massive,
life-threatening hemorrhage. Cervical assessment must be done by ultrasound only. Monitoring vital signs and FHR, bed rest in side-lying
position, and IV access are all appropriate actions for this client.
Q13: A nurse cares for a client at 30 weeks in preterm labor. The provider prescribes terbutaline. Which is the expected
therapeutic effect?
A. Reduction of blood pressure and prevention of seizures
B. Relaxation of uterine smooth muscle and cessation of contractions **[CORRECT]**
C. Promotion of fetal lung maturity
Page 3
NUR 2513 / NUR2513 Exam 2 (Latest ):
Maternal Child Nursing - Rasmussen
Questions and Verified Answers | 100% Correct | Modules 3-5
Rasmussen University | 75 Questions | 75 Minutes | 2026-2027 Curriculum Standards
Section 1: Labor and Birth (Q1-Q25)
Stages of Labor, Cervical Assessment, Induction of Labor, FHR Monitoring, Labor Complications
Q1: A nurse is caring for a client in the active phase of the first stage of labor. The client is 7 cm dilated, 90% effaced, and
the fetus is at +1 station. Which of the following findings should the nurse expect during this phase?
A. Contractions occur every 2-3 minutes, lasting 60-90 seconds, and are moderate to strong in intensity **[CORRECT]**
B. The client reports an urge to push and rectal pressure is present
C. Contractions occur every 5-6 minutes, lasting 30-40 seconds, and are mild in intensity
D. The placenta is delivered and the fundus is firm at midline
Correct Answer: A
Rationale: The active phase of the first stage is characterized by cervical dilation from 4-7 cm with contractions every 2-3 minutes, lasting
60-90 seconds, and moderate to strong intensity. Option B describes the transition phase or second stage with the urge to push. Option C
describes the latent phase with mild contractions. Option D describes the third stage involving placental delivery, not the active phase of the first
stage.
Q2: A nurse performs a sterile vaginal exam and notes the cervix is 5 cm dilated, 50% effaced, and the presenting part is at -2
station. The nurse correctly identifies the presenting part is located at which position?
A. 2 cm above the ischial spines **[CORRECT]**
B. 2 cm below the ischial spines
C. At the level of the ischial spines
D. 5 cm above the ischial spines
Correct Answer: A
Rationale: Station describes the relationship of the presenting part to the ischial spines. Negative stations (-3 to -1) indicate the presenting part is
above the ischial spines. At -2 station, the presenting part is 2 cm above the ischial spines. Station 0 means at the level of the ischial spines, and
positive stations (+1 to +3) indicate below. This is a fundamental Rasmussen NUR 2513 cervical assessment concept.
Q3: A nurse is caring for a client receiving oxytocin for induction of labor. The nurse notes contractions every 90 seconds
with less than 30 seconds of rest between contractions. Which is the priority nursing action?
A. Increase the oxytocin infusion rate to progress labor
B. Stop the oxytocin infusion and reposition the client on her left side **[CORRECT]**
C. Administer terbutaline subcutaneously
D. Prepare the client for an amniotomy
Correct Answer: B
Rationale: Contractions every 90 seconds with less than 30 seconds of rest indicate uterine hyperstimulation (tachysystole). The priority action is
to stop the oxytocin infusion immediately and reposition the client on her left side to improve uteroplacental perfusion. Increasing oxytocin
worsens hyperstimulation. Terbutaline may be needed if conservative measures fail, but stopping oxytocin and repositioning come first per
Rasmussen NUR 2513 protocol.
Q4: A nurse reviews the FHR tracing and observes decelerations that mirror the shape of the contraction, with the nadir
occurring at the same time as the peak of the contraction. The nurse identifies these as which type?
A. Variable decelerations
B. Prolonged decelerations
C. Early decelerations **[CORRECT]**
Page 1
,NUR 2513 Exam 2 | Maternal Child Nursing | Rasmussen University 75 Questions | 75 Minutes
D. Late decelerations
Correct Answer: C
Rationale: Early decelerations are caused by fetal head compression during contractions and have a uniform mirror-image shape with nadir at
the peak of the contraction. They are benign and require no intervention. Variable decelerations from cord compression have abrupt onset and
variable shape. Late decelerations from uteroplacental insufficiency have the nadir after the peak, an ominous sign requiring prompt
intervention.
Q5: A nurse monitors a client in labor and observes late decelerations on the FHR tracing. Which nursing intervention should
the nurse implement first?
A. Apply a fetal scalp electrode for more accurate monitoring
B. Reposition the client to the left lateral position and administer oxygen via face mask **[CORRECT]**
C. Prepare the client for an emergency cesarean delivery
D. Increase the IV fluid rate to 200 mL/hr
Correct Answer: B
Rationale: Late decelerations indicate uteroplacental insufficiency. The first priority interventions are intrauterine resuscitation: reposition the
client to the left lateral side to improve blood flow and administer oxygen at 8-10 L/min via face mask to maximize fetal oxygenation. C-section
may eventually be needed, but initial measures should correct the insufficiency first. A fetal scalp electrode does not address the cause.
Q6: A nurse is caring for a laboring client whose FHR tracing shows variable decelerations with moderate variability. Which
is the most likely cause of variable decelerations?
A. Fetal head compression
B. Uteroplacental insufficiency
C. Umbilical cord compression **[CORRECT]**
D. Fetal hypoxia
Correct Answer: C
Rationale: Variable decelerations are caused by compression of the umbilical cord, transiently reducing blood flow and oxygen to the fetus.
They have abrupt onset and recovery with variable shape and timing. Initial interventions include repositioning, amnioinfusion if membranes
are ruptured, and discontinuing oxytocin. Head compression causes early decelerations; uteroplacental insufficiency causes late decelerations.
Q7: A nurse assesses the FHR tracing and notes a baseline of 145 bpm with moderate variability (amplitude 12 bpm). No
decelerations are present. Two spontaneous accelerations of 15 bpm above baseline are noted, each lasting 15 seconds. The
nurse interprets this tracing as which category?
A. Category I - reassuring FHR pattern **[CORRECT]**
B. Category II - indeterminate FHR pattern
C. Category III - abnormal FHR pattern
D. Non-reassuring FHR pattern requiring immediate intervention
Correct Answer: A
Rationale: This tracing meets all Category I criteria: normal baseline (110-160 bpm), moderate variability (6-25 bpm), accelerations present,
and absence of late or variable decelerations. Category I patterns are strongly associated with normal fetal acid-base status and require no
intervention. Category II is indeterminate requiring evaluation. Category III is abnormal requiring prompt intervention.
Q8: A client at 39 weeks gestation is being prepared for induction of labor due to gestational hypertension. Which is a
required pre-induction assessment?
A. Performing a biophysical profile to assess amniotic fluid volume only
B. Assessing cervical readiness (Bishop score) and confirming fetal presentation and engagement **[CORRECT]**
C. Obtaining a STAT CBC to rule out maternal anemia
D. Performing a contraction stress test to confirm fetal well-being
Correct Answer: B
Rationale: Before induction, the nurse must assess cervical readiness using the Bishop score (dilation, effacement, station, consistency, position).
A score of 8+ indicates high likelihood of successful induction. Fetal presentation and engagement must also be confirmed, as induction with
unengaged presenting part increases cord prolapse risk. Biophysical profile, CBC, and contraction stress test are not routine pre-induction
Page 2
, NUR 2513 Exam 2 | Maternal Child Nursing | Rasmussen University 75 Questions | 75 Minutes
requirements per Rasmussen NUR 2513.
Q9: A nurse cares for a client in the transition phase at 9 cm dilation who reports intense pressure and the urge to push.
Which nursing response is most appropriate?
A. Encourage the client to bear down with each contraction
B. Instruct the client to breathe through the urge to push using pant-blow breathing **[CORRECT]**
C. Administer butorphanol as prescribed for pain management
D. Prepare the client for immediate vacuum-assisted delivery
Correct Answer: B
Rationale: During transition (8-10 cm), the client often feels a strong urge to push, but pushing before full dilation (10 cm) can cause cervical
edema and lacerations. The nurse should instruct the client to pant-blow through contractions to resist pushing until complete dilation. Bearing
down is contraindicated. Opioids are avoided this close to delivery. Vacuum delivery is for the second stage, not transition.
Q10: A nurse monitors a client receiving magnesium sulfate for preeclampsia. Which finding indicates magnesium toxicity?
A. Respiratory rate of 18 breaths/min, DTRs 2+, urinary output 40 mL/hr
B. Respiratory rate of 10 breaths/min, absent DTRs, urinary output 20 mL/hr **[CORRECT]**
C. Blood pressure 150/90 mmHg, headache, visual disturbances
D. Heart rate 110 bpm, flushing, feeling of warmth
Correct Answer: B
Rationale: Magnesium toxicity is indicated by respiratory depression (rate below 12/min), loss of deep tendon reflexes, and oliguria (below 30
mL/hr). These cardinal signs require calcium gluconate as the antidote. Option A shows normal findings. Option C describes preeclampsia
itself. Option D describes common non-toxic side effects of magnesium sulfate therapy.
Q11: A client at 35 weeks presents with sudden onset of severe abdominal pain and dark red vaginal bleeding. The uterus is
firm and board-like. The nurse should prepare the client for which of the following?
A. Immediate cesarean delivery for placenta previa
B. Expectant management with bed rest and pelvic rest
C. Emergency delivery for placental abruption **[CORRECT]**
D. Administration of oxytocin to augment labor
Correct Answer: C
Rationale: The classic triad of placental abruption is sudden severe abdominal pain with dark red bleeding and a firm, board-like uterus from
tetanic contractions. This obstetric emergency requires immediate delivery, usually via emergency C-section. Placenta previa presents with
painless bright red bleeding and soft uterus. Expectant management is inappropriate for acute abruption. Oxytocin is contraindicated in
abruption.
Q12: A client at 32 weeks is diagnosed with placenta previa covering the internal cervical os. The client reports bright red
vaginal bleeding. Which nursing action is contraindicated?
A. Assessing vital signs and fetal heart rate every 15 minutes
B. Performing a sterile vaginal examination to assess cervical dilation **[CORRECT]**
C. Placing the client on bed rest in a side-lying position
D. Initiating IV access with a large-bore catheter
Correct Answer: B
Rationale: In placenta previa, vaginal examinations are absolutely contraindicated because they can disrupt the placenta and cause massive,
life-threatening hemorrhage. Cervical assessment must be done by ultrasound only. Monitoring vital signs and FHR, bed rest in side-lying
position, and IV access are all appropriate actions for this client.
Q13: A nurse cares for a client at 30 weeks in preterm labor. The provider prescribes terbutaline. Which is the expected
therapeutic effect?
A. Reduction of blood pressure and prevention of seizures
B. Relaxation of uterine smooth muscle and cessation of contractions **[CORRECT]**
C. Promotion of fetal lung maturity
Page 3
