RASMUSSEN COLLEGE
Bachelor of Science in Nursing (BSN)
NUR2513 Maternal-Child Nursing
Academic Year: 2026/2027 Exam 1 · Complete Question Bank
Question 1
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:
The vastus lateralis is the preferred IM site for newborns. The deltoid is not used in newborns; vitamin K
should be given after the first feeding, not before.
Question 2
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 supports the lower uterine segment while the other palpates the fundus to assess for tone and
location.
, Question 3
Providing care to the postpartum client, the nurse recognizes that women are hypercoagulable
during the third trimester. Which assessments should be included for venous
thromboembolism? (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:
DVT risk is greatest in lower extremities; respiratory changes (tachypnea, dyspnea) and lung sounds may
indicate pulmonary embolism. Upper extremities are less common.
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 can cause illness. They do not
yet understand cause and effect or body functions fully.
, Question 5
A new mother asks the nurse how soon she can try to breastfeed after delivery. Which 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:
Early breastfeeding should be initiated within the first hour after birth to promote bonding and
successful feeding.
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 sign of developmental dysplasia of the hip (DDH). Crying on straightening is
less specific; foot rotation is not indicative.
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:
Lochia rubra (red) is normal for the first 1–3 days postpartum. Large clots, >500 mL bleeding, and a
boggy uterus are abnormal.
, Question 8
A nurse is caring for an infant with myelomeningocele. Which action should the nurse include
in the preoperative plan of care?
A. Place the infant in a supine position
B. Assess the infant's temperature 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:
The sac should be covered with a sterile, moist (saline) dressing to prevent drying and rupture. Supine
positioning and avoiding rectal temps are also important, but moisture is key.
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 newborns; it is normally adherent and will separate
naturally over time.
Bachelor of Science in Nursing (BSN)
NUR2513 Maternal-Child Nursing
Academic Year: 2026/2027 Exam 1 · Complete Question Bank
Question 1
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:
The vastus lateralis is the preferred IM site for newborns. The deltoid is not used in newborns; vitamin K
should be given after the first feeding, not before.
Question 2
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 supports the lower uterine segment while the other palpates the fundus to assess for tone and
location.
, Question 3
Providing care to the postpartum client, the nurse recognizes that women are hypercoagulable
during the third trimester. Which assessments should be included for venous
thromboembolism? (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:
DVT risk is greatest in lower extremities; respiratory changes (tachypnea, dyspnea) and lung sounds may
indicate pulmonary embolism. Upper extremities are less common.
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 can cause illness. They do not
yet understand cause and effect or body functions fully.
, Question 5
A new mother asks the nurse how soon she can try to breastfeed after delivery. Which 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:
Early breastfeeding should be initiated within the first hour after birth to promote bonding and
successful feeding.
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 sign of developmental dysplasia of the hip (DDH). Crying on straightening is
less specific; foot rotation is not indicative.
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:
Lochia rubra (red) is normal for the first 1–3 days postpartum. Large clots, >500 mL bleeding, and a
boggy uterus are abnormal.
, Question 8
A nurse is caring for an infant with myelomeningocele. Which action should the nurse include
in the preoperative plan of care?
A. Place the infant in a supine position
B. Assess the infant's temperature 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:
The sac should be covered with a sterile, moist (saline) dressing to prevent drying and rupture. Supine
positioning and avoiding rectal temps are also important, but moisture is key.
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 newborns; it is normally adherent and will separate
naturally over time.
