NURS 306 Quiz 7 V2 | NURS 306 OB |
Actual Q&A with Rationale (NURS306 Quiz
7) | West Coast University
1. A nurse is assessing a postpartum client 2 hours after delivery and notes that the fundus is
boggy and displaced to the right. Which of the following actions should the nurse take first?
A. Perform fundal massage
B. Administer oxytocin
C. Assist the client to void
D. Notify the provider
Answer: C
Rationale: A fundus that is displaced to the right and boggy typically indicates a full
bladder, which prevents the uterus from contracting effectively. Assisting the client to
empty their bladder is the priority intervention to allow the uterus to return to the midline
and firm up. If the fundus remains boggy after voiding, then fundal massage and
pharmacological interventions would follow.
2. A nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. The
nurse notes a respiratory rate of 10/min and absent deep tendon reflexes (DTRs). Which of
the following medications should the nurse prepare to administer?
A. Naloxone
,B. Terbutaline
C. Calcium gluconate
D. Hydralazine
Answer: C
Rationale: Calcium gluconate is the specific antidote for magnesium sulfate toxicity, which
is manifested by respiratory depression and loss of deep tendon reflexes. The nurse must
immediately stop the magnesium infusion and administer the antidote to prevent cardiac
or respiratory arrest. Monitoring the client’s magnesium levels and vital signs is critical
throughout the treatment process.
3. A nurse is evaluating the electronic fetal monitor (EFM) strip of a client in labor and
observes late decelerations. Which of the following is the priority nursing action?
A. Increase the rate of the oxytocin infusion
B. Administer oxygen via nasal cannula at 2 L/min
C. Perform a vaginal exam
D. Reposition the client to a side-lying position
Answer: D
Rationale: Late decelerations are indicative of uteroplacental insufficiency, which poses a
risk for fetal hypoxia. Turning the client to a side-lying position improves blood flow to the
placenta and is the first step in intrauterine resuscitation. Other steps include stopping
,oxytocin, increasing IV fluids, and administering oxygen via a non-rebreather mask at 8-10
L/min.
4. A nurse is providing discharge teaching to a new parent about umbilical cord care. Which of
the following instructions should the nurse include?
A. Apply petroleum jelly to the cord stump twice daily
B. Pull the cord off if it is hanging by a small thread
C. Give the baby a tub bath every day until the cord falls off
D. Keep the cord stump clean and dry
Answer: D
Rationale: The umbilical cord should be kept clean and dry to prevent infection and
facilitate the drying process. Parents should be instructed to fold the diaper below the cord
to avoid irritation and exposure to urine. Tub baths should be avoided until the cord has
naturally fallen off, which usually occurs within 10 to 14 days.
5. A nurse is caring for a newborn who was born at 38 weeks of gestation to a client who has
type 1 diabetes mellitus. The nurse should monitor the newborn for which of the following
complications?
A. Hypercalcemia
B. Hyperglycemia
C. Hypoglycemia
, D. Polyuria
Answer: C
Rationale: Infants of diabetic mothers are at high risk for hypoglycemia after birth because
their own insulin production remains high while the maternal glucose supply is cut off. The
nurse should monitor the newborn’s blood glucose levels shortly after birth and observe
for signs like jitteriness, lethargy, or poor feeding. Early and frequent feedings are
recommended to maintain stable blood sugar levels.
6. A nurse is assessing a client who is 32 weeks of gestation and reports painless, bright red
vaginal bleeding. Which of the following conditions should the nurse suspect?
A. Abruptio placentae
B. Preterm labor
C. Uterine rupture
D. Placenta previa
Answer: D
Rationale: Painless, bright red vaginal bleeding during the second or third trimester is the
classic sign of placenta previa. In contrast, abruptio placentae typically presents with
painful, dark red bleeding and uterine tenderness. It is vital to avoid vaginal examinations
in these clients until the location of the placenta is confirmed by ultrasound to prevent
hemorrhage.
Actual Q&A with Rationale (NURS306 Quiz
7) | West Coast University
1. A nurse is assessing a postpartum client 2 hours after delivery and notes that the fundus is
boggy and displaced to the right. Which of the following actions should the nurse take first?
A. Perform fundal massage
B. Administer oxytocin
C. Assist the client to void
D. Notify the provider
Answer: C
Rationale: A fundus that is displaced to the right and boggy typically indicates a full
bladder, which prevents the uterus from contracting effectively. Assisting the client to
empty their bladder is the priority intervention to allow the uterus to return to the midline
and firm up. If the fundus remains boggy after voiding, then fundal massage and
pharmacological interventions would follow.
2. A nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. The
nurse notes a respiratory rate of 10/min and absent deep tendon reflexes (DTRs). Which of
the following medications should the nurse prepare to administer?
A. Naloxone
,B. Terbutaline
C. Calcium gluconate
D. Hydralazine
Answer: C
Rationale: Calcium gluconate is the specific antidote for magnesium sulfate toxicity, which
is manifested by respiratory depression and loss of deep tendon reflexes. The nurse must
immediately stop the magnesium infusion and administer the antidote to prevent cardiac
or respiratory arrest. Monitoring the client’s magnesium levels and vital signs is critical
throughout the treatment process.
3. A nurse is evaluating the electronic fetal monitor (EFM) strip of a client in labor and
observes late decelerations. Which of the following is the priority nursing action?
A. Increase the rate of the oxytocin infusion
B. Administer oxygen via nasal cannula at 2 L/min
C. Perform a vaginal exam
D. Reposition the client to a side-lying position
Answer: D
Rationale: Late decelerations are indicative of uteroplacental insufficiency, which poses a
risk for fetal hypoxia. Turning the client to a side-lying position improves blood flow to the
placenta and is the first step in intrauterine resuscitation. Other steps include stopping
,oxytocin, increasing IV fluids, and administering oxygen via a non-rebreather mask at 8-10
L/min.
4. A nurse is providing discharge teaching to a new parent about umbilical cord care. Which of
the following instructions should the nurse include?
A. Apply petroleum jelly to the cord stump twice daily
B. Pull the cord off if it is hanging by a small thread
C. Give the baby a tub bath every day until the cord falls off
D. Keep the cord stump clean and dry
Answer: D
Rationale: The umbilical cord should be kept clean and dry to prevent infection and
facilitate the drying process. Parents should be instructed to fold the diaper below the cord
to avoid irritation and exposure to urine. Tub baths should be avoided until the cord has
naturally fallen off, which usually occurs within 10 to 14 days.
5. A nurse is caring for a newborn who was born at 38 weeks of gestation to a client who has
type 1 diabetes mellitus. The nurse should monitor the newborn for which of the following
complications?
A. Hypercalcemia
B. Hyperglycemia
C. Hypoglycemia
, D. Polyuria
Answer: C
Rationale: Infants of diabetic mothers are at high risk for hypoglycemia after birth because
their own insulin production remains high while the maternal glucose supply is cut off. The
nurse should monitor the newborn’s blood glucose levels shortly after birth and observe
for signs like jitteriness, lethargy, or poor feeding. Early and frequent feedings are
recommended to maintain stable blood sugar levels.
6. A nurse is assessing a client who is 32 weeks of gestation and reports painless, bright red
vaginal bleeding. Which of the following conditions should the nurse suspect?
A. Abruptio placentae
B. Preterm labor
C. Uterine rupture
D. Placenta previa
Answer: D
Rationale: Painless, bright red vaginal bleeding during the second or third trimester is the
classic sign of placenta previa. In contrast, abruptio placentae typically presents with
painful, dark red bleeding and uterine tenderness. It is vital to avoid vaginal examinations
in these clients until the location of the placenta is confirmed by ultrasound to prevent
hemorrhage.
