MATERNAL-CHILD NURSING (NUR2513)
COMPREHENSIVE EXAM
1. A nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. Which of
the following findings should the nurse identify as a manifestation of magnesium toxicity?
A. Hyperreflexia
B. Urine output of 40 mL/hr
C. Blood pressure of 150/95 mmHg
D. Respiratory rate of 10/min
Answer: D
Conceptual Explanation: A respiratory rate of less than 12/min is a primary sign of
magnesium toxicity. Other signs include loss of deep tendon reflexes and decreased urine
output.
2. A nurse is monitoring a fetal heart rate (FHR) tracing and notes late decelerations. Which of
the following actions should the nurse take first?
A. Turn the client to a side-lying position
B. Apply oxygen via non-rebreather mask
C. Increase the IV fluid rate
,D. Notify the provider
Answer: A
Conceptual Explanation: Repositioning the client to a side-lying position is the first action
to improve placental perfusion and oxygenation to the fetus.
3. A client in labor is in the transition phase. She is irritable and says, ‘I can’t do this
anymore.’ Which of the following actions is appropriate for the nurse?
A. Encourage the client to take a nap
B. Administer an oral analgesic
C. Suggest the client walk in the hallway
D. Provide firm, direct instructions for breathing
Answer: D
Conceptual Explanation: During the transition phase, clients often lose focus and require
clear, direct coaching to manage contractions and breathing.
4. Which assessment finding is the most critical to report in a client who is 4 hours
postpartum?
A. Fundus firm and 1 cm above the umbilicus
B. Lochia rubra with small clots
C. Urine output of 200 mL since delivery
D. Heart rate of 110 bpm and low blood pressure
, Answer: D
Conceptual Explanation: Tachycardia and hypotension are signs of hypovolemic shock,
suggesting postpartum hemorrhage.
5. An infant has a heart rate of 110, slow/irregular respirations, some flexion of extremities, a
grimace when stimulated, and a pink body with blue extremities. What is the Apgar score?
A. 5
B. 6
C. 7
D. 8
Answer: B
Conceptual Explanation: HR=2, Resp=1, Tone=1, Reflex=1, Color=1. Total = 6.
6. According to Erikson, which developmental stage is typical for a 2-year-old child?
A. Autonomy vs. Shame and Doubt
B. Industry vs. Inferiority
C. Trust vs. Mistrust
D. Initiative vs. Guilt
Answer: A
COMPREHENSIVE EXAM
1. A nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. Which of
the following findings should the nurse identify as a manifestation of magnesium toxicity?
A. Hyperreflexia
B. Urine output of 40 mL/hr
C. Blood pressure of 150/95 mmHg
D. Respiratory rate of 10/min
Answer: D
Conceptual Explanation: A respiratory rate of less than 12/min is a primary sign of
magnesium toxicity. Other signs include loss of deep tendon reflexes and decreased urine
output.
2. A nurse is monitoring a fetal heart rate (FHR) tracing and notes late decelerations. Which of
the following actions should the nurse take first?
A. Turn the client to a side-lying position
B. Apply oxygen via non-rebreather mask
C. Increase the IV fluid rate
,D. Notify the provider
Answer: A
Conceptual Explanation: Repositioning the client to a side-lying position is the first action
to improve placental perfusion and oxygenation to the fetus.
3. A client in labor is in the transition phase. She is irritable and says, ‘I can’t do this
anymore.’ Which of the following actions is appropriate for the nurse?
A. Encourage the client to take a nap
B. Administer an oral analgesic
C. Suggest the client walk in the hallway
D. Provide firm, direct instructions for breathing
Answer: D
Conceptual Explanation: During the transition phase, clients often lose focus and require
clear, direct coaching to manage contractions and breathing.
4. Which assessment finding is the most critical to report in a client who is 4 hours
postpartum?
A. Fundus firm and 1 cm above the umbilicus
B. Lochia rubra with small clots
C. Urine output of 200 mL since delivery
D. Heart rate of 110 bpm and low blood pressure
, Answer: D
Conceptual Explanation: Tachycardia and hypotension are signs of hypovolemic shock,
suggesting postpartum hemorrhage.
5. An infant has a heart rate of 110, slow/irregular respirations, some flexion of extremities, a
grimace when stimulated, and a pink body with blue extremities. What is the Apgar score?
A. 5
B. 6
C. 7
D. 8
Answer: B
Conceptual Explanation: HR=2, Resp=1, Tone=1, Reflex=1, Color=1. Total = 6.
6. According to Erikson, which developmental stage is typical for a 2-year-old child?
A. Autonomy vs. Shame and Doubt
B. Industry vs. Inferiority
C. Trust vs. Mistrust
D. Initiative vs. Guilt
Answer: A
