NUR2513 Maternal-Child Nursing
Exam 2 Test Bank (400 Questions
with Explanational Rationales,
2026 Edition)
This premium, high-yield study resource contains
400 comprehensive multiple-choice practice
questions specifically engineered for the NUR2513
Maternal-Child Nursing Exam 2. Each question
features the correct answer highlighted in bold italics
alongside a detailed clinical rationale to help you
master complex postpartum care, labor stages, fetal
monitor tracings, and pediatric milestones. Ideal for
last-minute cramming or structured review, this
document is guaranteed to boost your confidence
and help you secure an A on exam day.
,Question 1
A nurse is assessing a postpartum client 2 hours after a vaginal delivery. The nurse
notes that the client's fundus is soft, boggy, and displaced upwards and to the right of
the umbilicus. Which action should the nurse implement first?
A) Administer a prescribed dose of oxytocin IM.
B) Assist the client to the bathroom to void.
C) Perform a rapid, vigorous fundal massage.
D) Notify the healthcare provider of a potential hemorrhage.
Answer: B
Rationale: A postpartum fundus that is soft, boggy, and displaced to the right of the
umbilicus typically indicates a distended bladder. A full bladder displaces the uterus,
preventing efficient uterine contractions and increasing the risk of postpartum
hemorrhage. Assisting the patient to empty her bladder must occur before reassessing
uterine firmness. While fundal massage is crucial for a boggy uterus, addressing the
root cause (bladder distention) is the clinical priority.
Question 2
The nurse is reviewing an electronic fetal monitor tracing for a client in active labor and
notes a pattern of late decelerations. Which of the following root causes is associated
with this specific fetal heart rate finding?
A) Fetal head compression against the pelvis
B) Umbilical cord compression during contractions
C) Uteroplacental insufficiency reducing oxygenation
D) Sudden maternal position changes from side to side
Answer: C
Rationale: Late decelerations are an ominous sign caused by uteroplacental
insufficiency, which results in diminished fetal oxygenation during contractions. Fetal
head compression produces benign early decelerations. Umbilical cord compression
results in variable decelerations. Distinguishing these patterns is critical for targeted
maternal-fetal nursing interventions.
Question 3
A client is admitted to the labor and delivery unit at 34 weeks gestation with a chief
complaint of sudden-onset, painless, bright red vaginal bleeding. The fetal heart rate is
reassuring at 142 bpm. Which condition should the nurse suspect?
A) Abruptio Placentae
B) Placenta Previa
C) Advanced cervical dilation
D) Ruptured amniotic sac
,Answer: B
Rationale: Painless, bright red vaginal bleeding in the second or third trimester is the
classic hallmark sign of placenta previa. Abruptio placentae also presents with vaginal
bleeding, but it is characteristically accompanied by severe abdominal pain, uterine
tenderness, and a rigid abdomen. Vaginal examinations are strictly contraindicated if
placenta previa is suspected.
Question 4
A nurse is preparing to administer an intramuscular injection of phytonadione (Vitamin
K) to a newborn within the first hour of birth. Which explanation should the nurse
provide to the parents regarding the primary purpose of this medication?
A) It stimulates the development of a functional immune system.
B) It aids the immature liver in conjugating bilirubin.
C) It prevents serious neonatal hemorrhagic disorders.
D) It colonizes the sterile gut flora to improve digestion.
Answer: C
Rationale: Newborns are born with a sterile gut and lack the intestinal bacteria required
to synthesize Vitamin K, which is vital for the activation of clotting factors. Administering
phytonadione at birth prevents Vitamin K deficiency bleeding (VKDB), also known as
hemorrhagic disease of the newborn. It does not impact bilirubin conjugation or immune
system maturation.
Question 5
The nurse is conducting a postpartum assessment on a client who delivered 24 hours
ago. The nurse notes dark red lochia containing small shreds of tissue and mucus. How
should the nurse document this finding?
A) Lochia alba
B) Lochia serosa
C) Lochia rubra
D) Lochia purulenta
Answer: C
Rationale: Lochia rubra is the initial bright red to dark red vaginal discharge seen during
the first 1 to 3 days postpartum. It consists primarily of blood, mucus, and decidual
fragments. Lochia serosa is pinkish-brown and occurs from days 4 to 10. Lochia alba is
creamy white or light yellow and occurs from day 10 up to 6 weeks postpartum. This
finding is normal for 24 hours postpartum.
, Question 6
A nurse is assessing a term newborn who is 12 hours old. Which of the following clinical
findings requires immediate notification to the pediatrician?
A) Epstein's pearls on the hard palate
B) Acrocyanosis of the hands and feet
C) A blood glucose level of 32 mg/dL
D) Erythema toxicum on the chest and back
Answer: C
Rationale: Hypoglycemia in a term infant is generally defined as a blood glucose level
below 40 to 45 mg/dL. A level of 32 mg/dL requires prompt nursing intervention (feeding
or IV glucose) and provider notification to prevent neurological compromise. Epstein's
pearls, acrocyanosis, and erythema toxicum are all benign, normal newborn variations
that do not require emergency action.
Question 7
A nurse is monitoring a client diagnosed with severe preeclampsia who is receiving a
continuous intravenous infusion of magnesium sulfate. Which assessment finding
indicates a manifestation of magnesium sulfate toxicity?
A) Hyperactive deep tendon reflexes (4+)
B) Absence of deep tendon reflexes (0)
C) Urinary output of 50 mL/hour
D) Respiratory rate of 18 breaths/minute
Answer: B
Rationale: Magnesium sulfate is a central nervous system depressant used to prevent
seizures in preeclampsia. Signs of toxicity include the loss of deep tendon reflexes
(DTRs), respiratory depression (less than 12 breaths/minute), and decreased urine
output. Active DTRs and a normal respiratory rate show therapeutic management.
Calcium gluconate is the antidote and must be readily available.
Question 8
A nurse is caring for an infant born to a mother with an active, primary outbreak of
herpes simplex virus (HSV-2) with visible perineal lesions. What delivery approach does
the nurse expect to prepare for?
A) Standard vaginal delivery with prophylactic antibiotics
B) Vacuum-assisted vaginal delivery to expedite birth
C) Planned cesarean section prior to membrane rupture
D) Forceps-assisted delivery to limit vaginal transit time
Answer: C
Exam 2 Test Bank (400 Questions
with Explanational Rationales,
2026 Edition)
This premium, high-yield study resource contains
400 comprehensive multiple-choice practice
questions specifically engineered for the NUR2513
Maternal-Child Nursing Exam 2. Each question
features the correct answer highlighted in bold italics
alongside a detailed clinical rationale to help you
master complex postpartum care, labor stages, fetal
monitor tracings, and pediatric milestones. Ideal for
last-minute cramming or structured review, this
document is guaranteed to boost your confidence
and help you secure an A on exam day.
,Question 1
A nurse is assessing a postpartum client 2 hours after a vaginal delivery. The nurse
notes that the client's fundus is soft, boggy, and displaced upwards and to the right of
the umbilicus. Which action should the nurse implement first?
A) Administer a prescribed dose of oxytocin IM.
B) Assist the client to the bathroom to void.
C) Perform a rapid, vigorous fundal massage.
D) Notify the healthcare provider of a potential hemorrhage.
Answer: B
Rationale: A postpartum fundus that is soft, boggy, and displaced to the right of the
umbilicus typically indicates a distended bladder. A full bladder displaces the uterus,
preventing efficient uterine contractions and increasing the risk of postpartum
hemorrhage. Assisting the patient to empty her bladder must occur before reassessing
uterine firmness. While fundal massage is crucial for a boggy uterus, addressing the
root cause (bladder distention) is the clinical priority.
Question 2
The nurse is reviewing an electronic fetal monitor tracing for a client in active labor and
notes a pattern of late decelerations. Which of the following root causes is associated
with this specific fetal heart rate finding?
A) Fetal head compression against the pelvis
B) Umbilical cord compression during contractions
C) Uteroplacental insufficiency reducing oxygenation
D) Sudden maternal position changes from side to side
Answer: C
Rationale: Late decelerations are an ominous sign caused by uteroplacental
insufficiency, which results in diminished fetal oxygenation during contractions. Fetal
head compression produces benign early decelerations. Umbilical cord compression
results in variable decelerations. Distinguishing these patterns is critical for targeted
maternal-fetal nursing interventions.
Question 3
A client is admitted to the labor and delivery unit at 34 weeks gestation with a chief
complaint of sudden-onset, painless, bright red vaginal bleeding. The fetal heart rate is
reassuring at 142 bpm. Which condition should the nurse suspect?
A) Abruptio Placentae
B) Placenta Previa
C) Advanced cervical dilation
D) Ruptured amniotic sac
,Answer: B
Rationale: Painless, bright red vaginal bleeding in the second or third trimester is the
classic hallmark sign of placenta previa. Abruptio placentae also presents with vaginal
bleeding, but it is characteristically accompanied by severe abdominal pain, uterine
tenderness, and a rigid abdomen. Vaginal examinations are strictly contraindicated if
placenta previa is suspected.
Question 4
A nurse is preparing to administer an intramuscular injection of phytonadione (Vitamin
K) to a newborn within the first hour of birth. Which explanation should the nurse
provide to the parents regarding the primary purpose of this medication?
A) It stimulates the development of a functional immune system.
B) It aids the immature liver in conjugating bilirubin.
C) It prevents serious neonatal hemorrhagic disorders.
D) It colonizes the sterile gut flora to improve digestion.
Answer: C
Rationale: Newborns are born with a sterile gut and lack the intestinal bacteria required
to synthesize Vitamin K, which is vital for the activation of clotting factors. Administering
phytonadione at birth prevents Vitamin K deficiency bleeding (VKDB), also known as
hemorrhagic disease of the newborn. It does not impact bilirubin conjugation or immune
system maturation.
Question 5
The nurse is conducting a postpartum assessment on a client who delivered 24 hours
ago. The nurse notes dark red lochia containing small shreds of tissue and mucus. How
should the nurse document this finding?
A) Lochia alba
B) Lochia serosa
C) Lochia rubra
D) Lochia purulenta
Answer: C
Rationale: Lochia rubra is the initial bright red to dark red vaginal discharge seen during
the first 1 to 3 days postpartum. It consists primarily of blood, mucus, and decidual
fragments. Lochia serosa is pinkish-brown and occurs from days 4 to 10. Lochia alba is
creamy white or light yellow and occurs from day 10 up to 6 weeks postpartum. This
finding is normal for 24 hours postpartum.
, Question 6
A nurse is assessing a term newborn who is 12 hours old. Which of the following clinical
findings requires immediate notification to the pediatrician?
A) Epstein's pearls on the hard palate
B) Acrocyanosis of the hands and feet
C) A blood glucose level of 32 mg/dL
D) Erythema toxicum on the chest and back
Answer: C
Rationale: Hypoglycemia in a term infant is generally defined as a blood glucose level
below 40 to 45 mg/dL. A level of 32 mg/dL requires prompt nursing intervention (feeding
or IV glucose) and provider notification to prevent neurological compromise. Epstein's
pearls, acrocyanosis, and erythema toxicum are all benign, normal newborn variations
that do not require emergency action.
Question 7
A nurse is monitoring a client diagnosed with severe preeclampsia who is receiving a
continuous intravenous infusion of magnesium sulfate. Which assessment finding
indicates a manifestation of magnesium sulfate toxicity?
A) Hyperactive deep tendon reflexes (4+)
B) Absence of deep tendon reflexes (0)
C) Urinary output of 50 mL/hour
D) Respiratory rate of 18 breaths/minute
Answer: B
Rationale: Magnesium sulfate is a central nervous system depressant used to prevent
seizures in preeclampsia. Signs of toxicity include the loss of deep tendon reflexes
(DTRs), respiratory depression (less than 12 breaths/minute), and decreased urine
output. Active DTRs and a normal respiratory rate show therapeutic management.
Calcium gluconate is the antidote and must be readily available.
Question 8
A nurse is caring for an infant born to a mother with an active, primary outbreak of
herpes simplex virus (HSV-2) with visible perineal lesions. What delivery approach does
the nurse expect to prepare for?
A) Standard vaginal delivery with prophylactic antibiotics
B) Vacuum-assisted vaginal delivery to expedite birth
C) Planned cesarean section prior to membrane rupture
D) Forceps-assisted delivery to limit vaginal transit time
Answer: C
