NR-327 Maternal-Child Nursing Exam 2 Practice Questions
|Chamberlain
1. A nurse is monitoring a client in labor and observes variable decelerations on
the fetal heart rate monitor. What is the priority nursing intervention?
A. Change the client’s position
B. Increase the rate of IV fluids
C. Administer oxygen via non-rebreather mask
D. Prepare for immediate cesarean delivery
Answer: A
Rationale: Variable decelerations are typically caused by umbilical cord compression. The
priority nursing action is to change the mother’s position to relieve pressure on the cord.
2. Which of the following findings should the nurse report as a potential sign of
magnesium sulfate toxicity in a client with preeclampsia?
A. Blood pressure 140/90 mmHg
B. Urine output of 40 mL/hr
C. Presence of 2+ deep tendon reflexes
D. Respiratory rate of 10/min
Answer: D
Rationale: Signs of magnesium sulfate toxicity include respiratory depression (less than
12/min), loss of deep tendon reflexes, and decreased urine output.
,3. A postpartum nurse is assessing a client 2 hours after delivery. The fundus is
boggy and displaced to the right. What is the most appropriate initial action?
A. Assist the client to the bathroom to void
B. Administer oxytocin
C. Perform fundal massage
D. Notify the healthcare provider
Answer: A
Rationale: A fundus displaced to the right is usually caused by a full bladder. Assisting the
client to void should allow the uterus to return to the midline and contract.
4. Which medication is the antidote for magnesium sulfate toxicity?
A. Calcium gluconate
B. Naloxone
C. Terbutaline
D. Vitamin K
Answer: A
Rationale: Calcium gluconate is the specific antidote for magnesium sulfate toxicity and
should be kept at the bedside.
5. A nurse is evaluating a fetal heart rate strip and notes late decelerations.
Which condition is most likely associated with this pattern?
A. Fetal head compression
B. Uteroplacental insufficiency
C. Umbilical cord compression
D. Fetal sleep cycle
Answer: B
Rationale: Late decelerations are caused by uteroplacental insufficiency and indicate that
the fetus is not receiving adequate oxygen during contractions.
, 6. What is the primary purpose of administering Vitamin K (phytonadione) to a
newborn?
A. To prevent neonatal infection
B. To stimulate lung maturity
C. To treat neonatal jaundice
D. To prevent hemorrhagic disease of the newborn
Answer: D
Rationale: Newborns are born with low levels of Vitamin K because it does not cross the
placenta easily and the sterile gut does not yet produce it. Vitamin K is essential for blood
clotting.
7. A client at 32 weeks gestation is diagnosed with preterm labor. Which
medication should the nurse expect to administer to promote fetal lung
maturity?
A. Nifedipine
B. Betamethasone
C. Indomethacin
D. Magnesium sulfate
Answer: B
Rationale: Betamethasone is a corticosteroid given to mothers in preterm labor to
accelerate fetal lung surfactant production.
8. Which APGAR score at 5 minutes would require immediate intervention and
resuscitation?
A. 9
B. 7
C. 3
D. 8
Answer: C
|Chamberlain
1. A nurse is monitoring a client in labor and observes variable decelerations on
the fetal heart rate monitor. What is the priority nursing intervention?
A. Change the client’s position
B. Increase the rate of IV fluids
C. Administer oxygen via non-rebreather mask
D. Prepare for immediate cesarean delivery
Answer: A
Rationale: Variable decelerations are typically caused by umbilical cord compression. The
priority nursing action is to change the mother’s position to relieve pressure on the cord.
2. Which of the following findings should the nurse report as a potential sign of
magnesium sulfate toxicity in a client with preeclampsia?
A. Blood pressure 140/90 mmHg
B. Urine output of 40 mL/hr
C. Presence of 2+ deep tendon reflexes
D. Respiratory rate of 10/min
Answer: D
Rationale: Signs of magnesium sulfate toxicity include respiratory depression (less than
12/min), loss of deep tendon reflexes, and decreased urine output.
,3. A postpartum nurse is assessing a client 2 hours after delivery. The fundus is
boggy and displaced to the right. What is the most appropriate initial action?
A. Assist the client to the bathroom to void
B. Administer oxytocin
C. Perform fundal massage
D. Notify the healthcare provider
Answer: A
Rationale: A fundus displaced to the right is usually caused by a full bladder. Assisting the
client to void should allow the uterus to return to the midline and contract.
4. Which medication is the antidote for magnesium sulfate toxicity?
A. Calcium gluconate
B. Naloxone
C. Terbutaline
D. Vitamin K
Answer: A
Rationale: Calcium gluconate is the specific antidote for magnesium sulfate toxicity and
should be kept at the bedside.
5. A nurse is evaluating a fetal heart rate strip and notes late decelerations.
Which condition is most likely associated with this pattern?
A. Fetal head compression
B. Uteroplacental insufficiency
C. Umbilical cord compression
D. Fetal sleep cycle
Answer: B
Rationale: Late decelerations are caused by uteroplacental insufficiency and indicate that
the fetus is not receiving adequate oxygen during contractions.
, 6. What is the primary purpose of administering Vitamin K (phytonadione) to a
newborn?
A. To prevent neonatal infection
B. To stimulate lung maturity
C. To treat neonatal jaundice
D. To prevent hemorrhagic disease of the newborn
Answer: D
Rationale: Newborns are born with low levels of Vitamin K because it does not cross the
placenta easily and the sterile gut does not yet produce it. Vitamin K is essential for blood
clotting.
7. A client at 32 weeks gestation is diagnosed with preterm labor. Which
medication should the nurse expect to administer to promote fetal lung
maturity?
A. Nifedipine
B. Betamethasone
C. Indomethacin
D. Magnesium sulfate
Answer: B
Rationale: Betamethasone is a corticosteroid given to mothers in preterm labor to
accelerate fetal lung surfactant production.
8. Which APGAR score at 5 minutes would require immediate intervention and
resuscitation?
A. 9
B. 7
C. 3
D. 8
Answer: C
