NR327/NR 327 Exam 3 V1 | Maternal Child Nursing
Q&A with Rationale | Chamberlain University
1. A nurse is assessing a postpartum client who is 4 hours post-delivery and notes a boggy
uterus that is displaced to the right of the midline. Which of the following is the priority
nursing intervention?
A. Administer oxytocin 10 units intramuscularly.
B. Perform a vigorous fundal massage.
C. Assist the client to empty her bladder.
D. Increase the rate of intravenous fluids.
Correct Answer: C
Explanation: A displaced uterus, especially to the right, is a classic sign of bladder
distention. A full bladder prevents the uterus from contracting effectively, which increases
the risk of postpartum hemorrhage. The nurse should assist the client to void before
reassessing the fundus for firmness and position.
2. A nurse is caring for a client receiving Magnesium Sulfate for preeclampsia. Which of the
following findings should the nurse report to the provider as a sign of toxicity?
A. Deep tendon reflexes (DTR) of 2+.
B. Urinary output of 40 mL per hour.
C. Respiratory rate of 10 breaths per minute.
,D. Blood pressure of 150/95 mmHg.
Correct Answer: C
Explanation: Magnesium Sulfate is a central nervous system depressant, and respiratory
depression (less than 12/min) is a critical sign of toxicity. The nurse must also monitor for
the loss of deep tendon reflexes and a significant drop in urinary output. Prompt
recognition of these signs is essential to prevent cardiac or respiratory arrest.
3. Which of the following interventions should the nurse prioritize for a newborn receiving
phototherapy for hyperbilirubinemia?
A. Applying lotion to the infant’s skin to prevent dryness.
B. Limiting fluid intake to prevent overhydration.
C. Ensuring the infant wears a diaper and eye shields.
D. Keeping the infant in a prone position for the duration of therapy.
Correct Answer: C
Explanation: Eye shields are mandatory to protect the newborn’s retina from the high-
intensity light used in phototherapy. The infant should be dressed only in a diaper to
maximize the skin surface area exposed to the light. The nurse must also monitor for
dehydration and skin integrity during the treatment process.
4. A client at 32 weeks of gestation is admitted with painless, bright red vaginal bleeding.
Which of the following actions is contraindicated?
A. Initiating external fetal monitoring.
, B. Performing a sterile vaginal examination.
C. Obtaining a sample for a Kleihauer-Betke test.
D. Assessing the client’s hemoglobin and hematocrit.
Correct Answer: B
Explanation: Painless bright red bleeding is indicative of placenta previa. A vaginal
examination could perforate the placenta and cause catastrophic maternal and fetal
hemorrhage. Ultrasound is the preferred method to confirm placental placement before
any internal exams are considered.
5. A nurse is preparing to administer Betamethasone to a client at 30 weeks of gestation who
is in preterm labor. What is the primary purpose of this medication?
A. To promote fetal lung maturity.
B. To increase maternal blood glucose.
C. To stop uterine contractions.
D. To prevent neonatal group B streptococcus infection.
Correct Answer: A
Explanation: Betamethasone is a corticosteroid administered to the mother to stimulate
surfactant production in the fetus. This reduces the risk of respiratory distress syndrome
(RDS) in preterm infants. The medication is typically given in two doses, 24 hours apart, to
achieve maximum therapeutic effect.
Q&A with Rationale | Chamberlain University
1. A nurse is assessing a postpartum client who is 4 hours post-delivery and notes a boggy
uterus that is displaced to the right of the midline. Which of the following is the priority
nursing intervention?
A. Administer oxytocin 10 units intramuscularly.
B. Perform a vigorous fundal massage.
C. Assist the client to empty her bladder.
D. Increase the rate of intravenous fluids.
Correct Answer: C
Explanation: A displaced uterus, especially to the right, is a classic sign of bladder
distention. A full bladder prevents the uterus from contracting effectively, which increases
the risk of postpartum hemorrhage. The nurse should assist the client to void before
reassessing the fundus for firmness and position.
2. A nurse is caring for a client receiving Magnesium Sulfate for preeclampsia. Which of the
following findings should the nurse report to the provider as a sign of toxicity?
A. Deep tendon reflexes (DTR) of 2+.
B. Urinary output of 40 mL per hour.
C. Respiratory rate of 10 breaths per minute.
,D. Blood pressure of 150/95 mmHg.
Correct Answer: C
Explanation: Magnesium Sulfate is a central nervous system depressant, and respiratory
depression (less than 12/min) is a critical sign of toxicity. The nurse must also monitor for
the loss of deep tendon reflexes and a significant drop in urinary output. Prompt
recognition of these signs is essential to prevent cardiac or respiratory arrest.
3. Which of the following interventions should the nurse prioritize for a newborn receiving
phototherapy for hyperbilirubinemia?
A. Applying lotion to the infant’s skin to prevent dryness.
B. Limiting fluid intake to prevent overhydration.
C. Ensuring the infant wears a diaper and eye shields.
D. Keeping the infant in a prone position for the duration of therapy.
Correct Answer: C
Explanation: Eye shields are mandatory to protect the newborn’s retina from the high-
intensity light used in phototherapy. The infant should be dressed only in a diaper to
maximize the skin surface area exposed to the light. The nurse must also monitor for
dehydration and skin integrity during the treatment process.
4. A client at 32 weeks of gestation is admitted with painless, bright red vaginal bleeding.
Which of the following actions is contraindicated?
A. Initiating external fetal monitoring.
, B. Performing a sterile vaginal examination.
C. Obtaining a sample for a Kleihauer-Betke test.
D. Assessing the client’s hemoglobin and hematocrit.
Correct Answer: B
Explanation: Painless bright red bleeding is indicative of placenta previa. A vaginal
examination could perforate the placenta and cause catastrophic maternal and fetal
hemorrhage. Ultrasound is the preferred method to confirm placental placement before
any internal exams are considered.
5. A nurse is preparing to administer Betamethasone to a client at 30 weeks of gestation who
is in preterm labor. What is the primary purpose of this medication?
A. To promote fetal lung maturity.
B. To increase maternal blood glucose.
C. To stop uterine contractions.
D. To prevent neonatal group B streptococcus infection.
Correct Answer: A
Explanation: Betamethasone is a corticosteroid administered to the mother to stimulate
surfactant production in the fetus. This reduces the risk of respiratory distress syndrome
(RDS) in preterm infants. The medication is typically given in two doses, 24 hours apart, to
achieve maximum therapeutic effect.
