RASMUSSEN COLLEGE
NUR2513 Maternal-Child Nursing
Academic Year: 2026/2027 Exam 2 · Updated Q-Bank
Question 1
Providing care to the postpartum client, the nurse recognizes that women are hypercoagulable
during the third trimester of pregnancy. Assessment of this client should include evaluation for
the development of venous thromboembolism. Which of the follow should be included in this
eval? (Select all that apply)
A. Observe distal upper extremities for swelling/edema
B. Observe lower extremities for symmetry
C. Assess for uterine cramping
D. Observe respiratory rate and effort
E. Auscultate lung sounds
CORRECT ANSWER: B, D, E
RATIONALE:
Assess lower extremities for signs of DVT (asymmetry), and monitor respiratory status (rate, effort, lung
sounds) for signs of pulmonary embolism.
Question 2
A newborn is prescribed to receive Vitamin K 0.5 mg intramuscularly. How should the nurse
administer the medication to the newborn?
A. Provide medication immediately before breastfeeding
B. Administer medication into the vastus lateralis
C. Notify physician for swelling and irritation at the injection site
D. Administer the medication in the deltoid muscle
CORRECT ANSWER: B. Administer medication into the vastus lateralis
RATIONALE:
Vitamin K is administered IM in the vastus lateralis muscle, which is the preferred site for newborns.
, Question 3
Which technique is used to palpate the fundal height on a postpartum client?
A. Placing one hand on the fundus, one on the perineum
B. Resting both hands on the fundus
C. Palpating the fundus with only fingertip pressure
D. Placing one hand at the base of the uterus, one on the fundus
CORRECT ANSWER: D. Placing one hand at the base of the uterus, one on the fundus
RATIONALE:
One hand is placed at the base of the uterus to support it while the other hand palpates the fundus.
Question 4
A nurse is caring for a 4-year-old female. Which of the following is expected of a preschool-
aged child?
A. Describing manifestations of illness
B. Understanding cause of illness
C. Relating fears to magical thinking
D. Awareness of body function
CORRECT ANSWER: C. Relating fears to magical thinking
RATIONALE:
Preschoolers engage in magical thinking and may believe their thoughts or actions caused illness.
Question 5
A new mother asks the nurse how soon she can try to breastfeed after delivery. Which of the
following would be the nurse's best response?
A. Once the infant has his first feeding of formula
B. Immediately after birth
C. In 24 hours after her infant is given water
D. After the infant is allowed to rest
CORRECT ANSWER: B. Immediately after birth
RATIONALE:
Breastfeeding should be initiated as soon as possible after birth, ideally within the first hour, to promote
bonding and stimulate milk production.
, Question 6
Which assessment finding indicates to the nurse that a newborn has hip subluxation?
A. Crying on straightening of the right leg
B. Inward rotation of the right foot
C. Inability of the right hip to abduct
D. Drawing of the legs underneath while prone
CORRECT ANSWER: C. Inability of the right hip to abduct
RATIONALE:
Limited hip abduction is a key sign of hip subluxation or developmental dysplasia of the hip (DDH).
Question 7
A nurse is helping her postpartum client up to the bathroom for the first time after delivery.
Which finding indicates her lochia is within normal limits?
A. The color of the flow is red
B. Lochia contains large clots
C. The flow is over 500 mL
D. Her uterus is boggy and soft
CORRECT ANSWER: A. The color of the flow is red
RATIONALE:
Red lochia (lochia rubra) is normal for the first 1–3 days postpartum. Large clots, excessive flow, or a
boggy uterus are abnormal.
Question 8
A nurse is caring for an infant with myelomeningocele. Which of the following actions should
the nurse include in the preoperative plan of care?
A. Place the infant in a supine position
B. Assess the infant's temp rectally
C. Apply a sterile, moist dressing on the sac
D. Assist the caregiver with cuddling the infant
CORRECT ANSWER: C. Apply a sterile, moist dressing on the sac
RATIONALE:
A sterile, moist dressing is applied to the sac to prevent drying and infection until surgical repair can be
performed.
, Question 9
The nurse is inspecting a male newborn's genitalia. Which action should the nurse avoid when
conducting this assessment?
A. Palpating if testes are descended into the scrotal sac
B. Retracting the foreskin over the glans to assess for secretions
C. Inspecting if the urethral opening appears circular
D. Inspecting the genital area for irritated skin
CORRECT ANSWER: B. Retracting the foreskin over the glans to assess for secretions
RATIONALE:
The foreskin should not be forcibly retracted in a newborn; it is normally tight and will retract naturally
over time.
Question 10
During a home visit, the nurse determines that a toddler has a difficult temperament. What did
the nurse observe in this toddler? (Select all that apply)
A. Rhythmic
B. Minimal adaptability
C. Withdrawing
D. Intense mood
CORRECT ANSWER: B, C, D
RATIONALE:
A difficult temperament is characterized by minimal adaptability, withdrawal from new situations, and
intense mood reactions.
Question 11
The nurse instructs the parents of a newborn on actions to prevent sudden infant death
syndrome. Which observation indicates the teaching has been effective?
A. The baby is on an every 2-hr formula feeding schedule
B. Newborn is placed on the back to sleep
C. Parents signed a waiver refusing routine immunizations after birth
D. Mother removes a pacifier from the baby's mouth
CORRECT ANSWER: B. Newborn is placed on the back to sleep
RATIONALE:
Placing the infant on the back to sleep is the most effective measure to reduce the risk of SIDS.
NUR2513 Maternal-Child Nursing
Academic Year: 2026/2027 Exam 2 · Updated Q-Bank
Question 1
Providing care to the postpartum client, the nurse recognizes that women are hypercoagulable
during the third trimester of pregnancy. Assessment of this client should include evaluation for
the development of venous thromboembolism. Which of the follow should be included in this
eval? (Select all that apply)
A. Observe distal upper extremities for swelling/edema
B. Observe lower extremities for symmetry
C. Assess for uterine cramping
D. Observe respiratory rate and effort
E. Auscultate lung sounds
CORRECT ANSWER: B, D, E
RATIONALE:
Assess lower extremities for signs of DVT (asymmetry), and monitor respiratory status (rate, effort, lung
sounds) for signs of pulmonary embolism.
Question 2
A newborn is prescribed to receive Vitamin K 0.5 mg intramuscularly. How should the nurse
administer the medication to the newborn?
A. Provide medication immediately before breastfeeding
B. Administer medication into the vastus lateralis
C. Notify physician for swelling and irritation at the injection site
D. Administer the medication in the deltoid muscle
CORRECT ANSWER: B. Administer medication into the vastus lateralis
RATIONALE:
Vitamin K is administered IM in the vastus lateralis muscle, which is the preferred site for newborns.
, Question 3
Which technique is used to palpate the fundal height on a postpartum client?
A. Placing one hand on the fundus, one on the perineum
B. Resting both hands on the fundus
C. Palpating the fundus with only fingertip pressure
D. Placing one hand at the base of the uterus, one on the fundus
CORRECT ANSWER: D. Placing one hand at the base of the uterus, one on the fundus
RATIONALE:
One hand is placed at the base of the uterus to support it while the other hand palpates the fundus.
Question 4
A nurse is caring for a 4-year-old female. Which of the following is expected of a preschool-
aged child?
A. Describing manifestations of illness
B. Understanding cause of illness
C. Relating fears to magical thinking
D. Awareness of body function
CORRECT ANSWER: C. Relating fears to magical thinking
RATIONALE:
Preschoolers engage in magical thinking and may believe their thoughts or actions caused illness.
Question 5
A new mother asks the nurse how soon she can try to breastfeed after delivery. Which of the
following would be the nurse's best response?
A. Once the infant has his first feeding of formula
B. Immediately after birth
C. In 24 hours after her infant is given water
D. After the infant is allowed to rest
CORRECT ANSWER: B. Immediately after birth
RATIONALE:
Breastfeeding should be initiated as soon as possible after birth, ideally within the first hour, to promote
bonding and stimulate milk production.
, Question 6
Which assessment finding indicates to the nurse that a newborn has hip subluxation?
A. Crying on straightening of the right leg
B. Inward rotation of the right foot
C. Inability of the right hip to abduct
D. Drawing of the legs underneath while prone
CORRECT ANSWER: C. Inability of the right hip to abduct
RATIONALE:
Limited hip abduction is a key sign of hip subluxation or developmental dysplasia of the hip (DDH).
Question 7
A nurse is helping her postpartum client up to the bathroom for the first time after delivery.
Which finding indicates her lochia is within normal limits?
A. The color of the flow is red
B. Lochia contains large clots
C. The flow is over 500 mL
D. Her uterus is boggy and soft
CORRECT ANSWER: A. The color of the flow is red
RATIONALE:
Red lochia (lochia rubra) is normal for the first 1–3 days postpartum. Large clots, excessive flow, or a
boggy uterus are abnormal.
Question 8
A nurse is caring for an infant with myelomeningocele. Which of the following actions should
the nurse include in the preoperative plan of care?
A. Place the infant in a supine position
B. Assess the infant's temp rectally
C. Apply a sterile, moist dressing on the sac
D. Assist the caregiver with cuddling the infant
CORRECT ANSWER: C. Apply a sterile, moist dressing on the sac
RATIONALE:
A sterile, moist dressing is applied to the sac to prevent drying and infection until surgical repair can be
performed.
, Question 9
The nurse is inspecting a male newborn's genitalia. Which action should the nurse avoid when
conducting this assessment?
A. Palpating if testes are descended into the scrotal sac
B. Retracting the foreskin over the glans to assess for secretions
C. Inspecting if the urethral opening appears circular
D. Inspecting the genital area for irritated skin
CORRECT ANSWER: B. Retracting the foreskin over the glans to assess for secretions
RATIONALE:
The foreskin should not be forcibly retracted in a newborn; it is normally tight and will retract naturally
over time.
Question 10
During a home visit, the nurse determines that a toddler has a difficult temperament. What did
the nurse observe in this toddler? (Select all that apply)
A. Rhythmic
B. Minimal adaptability
C. Withdrawing
D. Intense mood
CORRECT ANSWER: B, C, D
RATIONALE:
A difficult temperament is characterized by minimal adaptability, withdrawal from new situations, and
intense mood reactions.
Question 11
The nurse instructs the parents of a newborn on actions to prevent sudden infant death
syndrome. Which observation indicates the teaching has been effective?
A. The baby is on an every 2-hr formula feeding schedule
B. Newborn is placed on the back to sleep
C. Parents signed a waiver refusing routine immunizations after birth
D. Mother removes a pacifier from the baby's mouth
CORRECT ANSWER: B. Newborn is placed on the back to sleep
RATIONALE:
Placing the infant on the back to sleep is the most effective measure to reduce the risk of SIDS.
