,NUR 2513 Exam 2 — Maternal-Child Nursing |
Rasmussen University | 2026/2027 Exam Prep
+ Practice 100 Q&A + Rationales
Q1. A client is 2 hours postpartum and the nurse notes a boggy uterus with heavy lochia
rubra. Which action should the nurse take first?
A. Massage the fundus
B. Administer oxytocin as prescribed
C. Insert a urinary catheter
D. Obtain a hemoglobin level
Correct Answer: A. Massage the fundus
Rationale: A boggy uterus with heavy bleeding indicates uterine atony, the most common
cause of postpartum hemorrhage. The first action is to massage the fundus to stimulate
contraction and expel clots. Oxytocin is administered after massage to maintain contraction. A
urinary catheter may be needed if a full bladder is preventing contraction, but massage comes
first. Hemoglobin level is important but does not address the immediate bleeding. The nurse
should also monitor vital signs and lochia.
Key Takeaway: Perform fundal massage first for a boggy uterus with heavy postpartum
bleeding.
Q2. A client at 34 weeks' gestation reports a sudden onset of bright red vaginal bleeding
without pain. Which condition should the nurse suspect?
A. Abruptio placentae
B. Placenta previa
C. Preterm labor
D. Vasa previa
Correct Answer: B. Placenta previa
Rationale: Placenta previa is characterized by painless, bright red vaginal bleeding in the
second or third trimester. Abruptio placentae typically presents with painful bleeding and a
,rigid abdomen. Preterm labor presents with contractions and cervical changes, not typically
painless bleeding. Vasa previa involves fetal vessel rupture and is rarer. The nurse should
avoid vaginal examinations and prepare for possible cesarean delivery.
Key Takeaway: Painless, bright red vaginal bleeding in late pregnancy suggests placenta
previa.
Q3. A nurse is monitoring a client receiving magnesium sulfate for preeclampsia. Which
finding should the nurse report to the provider as a sign of magnesium toxicity?
A. Urinary output of 40 mL/hr
B. Respiratory rate of 10/min
C. Deep tendon reflexes of 2+
D. Blood pressure of 150/95 mm Hg
Correct Answer: B. Respiratory rate of 10/min
Rationale: A respiratory rate below 12/min is a primary indicator of magnesium sulfate
toxicity. Other signs include absent deep tendon reflexes and decreased urinary output
(below 30 mL/hr). A urinary output of 40 mL/hr and deep tendon reflexes of 2+ are normal. A
blood pressure of 150/95 mm Hg is elevated but not a sign of magnesium toxicity. The nurse
should hold the magnesium sulfate and notify the provider immediately.
Key Takeaway: Respiratory rate below 12/min indicates magnesium toxicity; hold the infusion
and notify the provider.
Q4. A nurse is caring for a client in the active phase of labor who has a prolapsed umbilical
cord. Which action should the nurse take first?
A. Apply oxygen via non-rebreather mask at 10 L/min
B. Prepare the client for an immediate cesarean birth
C. Increase the IV fluid infusion rate
D. Perform a vaginal exam and apply upward pressure to the presenting part
Correct Answer: D. Perform a vaginal exam and apply upward pressure to the presenting part
Rationale: Umbilical cord prolapse is a life-threatening emergency. The priority is to relieve
pressure on the cord to maintain fetal oxygenation. The nurse should use a sterile gloved
, hand to push the presenting part away from the cord. This intervention is critical until a
cesarean delivery can be performed. Oxygen, IV fluids, and preparation for cesarean birth are
important but follow the immediate relief of cord compression.
Key Takeaway: Relieve cord pressure first with upward pressure on the presenting part for
umbilical cord prolapse.
Q5. A nurse is assessing a newborn 1 hour after birth. Which finding should the nurse identify
as a manifestation of respiratory distress?
A. Acrocyanosis
B. Abdominal breathing
C. Respiratory rate of 50/min
D. Nasal flaring
Correct Answer: D. Nasal flaring
Rationale: Nasal flaring is a classic sign of respiratory distress in a newborn as they attempt to
decrease airway resistance. Other signs include intercostal retractions and expiratory
grunting. Acrocyanosis and abdominal breathing are normal findings in the immediate
neonatal period. A respiratory rate of 50/min is within normal limits (30 to 60/min). The
nurse should assess for retractions and oxygen saturation and notify the provider.
Key Takeaway: Nasal flaring, grunting, and retractions are signs of neonatal respiratory
distress.
Q6. A client at 28 weeks' gestation is diagnosed with gestational diabetes. Which nursing
intervention is the priority for managing this condition at home?
A. Begin insulin therapy immediately
B. Initiate daily fetal movement counts and teach self-monitoring of blood glucose with diet
modification
C. Schedule an immediate cesarean delivery
D. Restrict all carbohydrate intake
Correct Answer: B. Initiate daily fetal movement counts and teach self-monitoring of blood
glucose with diet modification
Rasmussen University | 2026/2027 Exam Prep
+ Practice 100 Q&A + Rationales
Q1. A client is 2 hours postpartum and the nurse notes a boggy uterus with heavy lochia
rubra. Which action should the nurse take first?
A. Massage the fundus
B. Administer oxytocin as prescribed
C. Insert a urinary catheter
D. Obtain a hemoglobin level
Correct Answer: A. Massage the fundus
Rationale: A boggy uterus with heavy bleeding indicates uterine atony, the most common
cause of postpartum hemorrhage. The first action is to massage the fundus to stimulate
contraction and expel clots. Oxytocin is administered after massage to maintain contraction. A
urinary catheter may be needed if a full bladder is preventing contraction, but massage comes
first. Hemoglobin level is important but does not address the immediate bleeding. The nurse
should also monitor vital signs and lochia.
Key Takeaway: Perform fundal massage first for a boggy uterus with heavy postpartum
bleeding.
Q2. A client at 34 weeks' gestation reports a sudden onset of bright red vaginal bleeding
without pain. Which condition should the nurse suspect?
A. Abruptio placentae
B. Placenta previa
C. Preterm labor
D. Vasa previa
Correct Answer: B. Placenta previa
Rationale: Placenta previa is characterized by painless, bright red vaginal bleeding in the
second or third trimester. Abruptio placentae typically presents with painful bleeding and a
,rigid abdomen. Preterm labor presents with contractions and cervical changes, not typically
painless bleeding. Vasa previa involves fetal vessel rupture and is rarer. The nurse should
avoid vaginal examinations and prepare for possible cesarean delivery.
Key Takeaway: Painless, bright red vaginal bleeding in late pregnancy suggests placenta
previa.
Q3. A nurse is monitoring a client receiving magnesium sulfate for preeclampsia. Which
finding should the nurse report to the provider as a sign of magnesium toxicity?
A. Urinary output of 40 mL/hr
B. Respiratory rate of 10/min
C. Deep tendon reflexes of 2+
D. Blood pressure of 150/95 mm Hg
Correct Answer: B. Respiratory rate of 10/min
Rationale: A respiratory rate below 12/min is a primary indicator of magnesium sulfate
toxicity. Other signs include absent deep tendon reflexes and decreased urinary output
(below 30 mL/hr). A urinary output of 40 mL/hr and deep tendon reflexes of 2+ are normal. A
blood pressure of 150/95 mm Hg is elevated but not a sign of magnesium toxicity. The nurse
should hold the magnesium sulfate and notify the provider immediately.
Key Takeaway: Respiratory rate below 12/min indicates magnesium toxicity; hold the infusion
and notify the provider.
Q4. A nurse is caring for a client in the active phase of labor who has a prolapsed umbilical
cord. Which action should the nurse take first?
A. Apply oxygen via non-rebreather mask at 10 L/min
B. Prepare the client for an immediate cesarean birth
C. Increase the IV fluid infusion rate
D. Perform a vaginal exam and apply upward pressure to the presenting part
Correct Answer: D. Perform a vaginal exam and apply upward pressure to the presenting part
Rationale: Umbilical cord prolapse is a life-threatening emergency. The priority is to relieve
pressure on the cord to maintain fetal oxygenation. The nurse should use a sterile gloved
, hand to push the presenting part away from the cord. This intervention is critical until a
cesarean delivery can be performed. Oxygen, IV fluids, and preparation for cesarean birth are
important but follow the immediate relief of cord compression.
Key Takeaway: Relieve cord pressure first with upward pressure on the presenting part for
umbilical cord prolapse.
Q5. A nurse is assessing a newborn 1 hour after birth. Which finding should the nurse identify
as a manifestation of respiratory distress?
A. Acrocyanosis
B. Abdominal breathing
C. Respiratory rate of 50/min
D. Nasal flaring
Correct Answer: D. Nasal flaring
Rationale: Nasal flaring is a classic sign of respiratory distress in a newborn as they attempt to
decrease airway resistance. Other signs include intercostal retractions and expiratory
grunting. Acrocyanosis and abdominal breathing are normal findings in the immediate
neonatal period. A respiratory rate of 50/min is within normal limits (30 to 60/min). The
nurse should assess for retractions and oxygen saturation and notify the provider.
Key Takeaway: Nasal flaring, grunting, and retractions are signs of neonatal respiratory
distress.
Q6. A client at 28 weeks' gestation is diagnosed with gestational diabetes. Which nursing
intervention is the priority for managing this condition at home?
A. Begin insulin therapy immediately
B. Initiate daily fetal movement counts and teach self-monitoring of blood glucose with diet
modification
C. Schedule an immediate cesarean delivery
D. Restrict all carbohydrate intake
Correct Answer: B. Initiate daily fetal movement counts and teach self-monitoring of blood
glucose with diet modification
