NUR 2513 / NUR2513 Final Exam
(Latest ): Maternal
Child Nursing - Rasmussen
1. A primigravida at 32 weeks gestation presents for a routine prenatal visit.
Fundal height measurement is 28 cm. The nurse reviews the chart and notes
that at the 28-week visit, fundal height was 26 cm. Fetal heart rate is 142 bpm.
The patient reports feeling fetal movement daily. What is the PRIORITY nursing
action?
A. Prepare the patient for an immediate cesarean section
B. Notify the healthcare provider of the fundal height discrepancy and prepare for
further evaluation, such as ultrasound
C. Reassure the patient that fundal height measurements can vary and continue
routine care
D. Instruct the patient to increase caloric intake to promote fetal growth
Correct Answer: B
Rationale: Fundal height measurement is a screening tool for fetal growth. Between
20-34 weeks gestation, fundal height in centimeters should approximate
gestational age in weeks (±2-3 cm). This patient's fundal height at 32 weeks is 28
cm—a discrepancy of 4 cm, which exceeds the acceptable 2-3 cm variance.
Additionally, the fundal height has only increased 2 cm over 4 weeks, which is less
than the expected increase of approximately 1 cm per week. This may indicate
intrauterine growth restriction (IUGR), oligohydramnios, or incorrect dating,
requiring further evaluation with ultrasound.
,2. A client at 8 weeks gestation tells the nurse, "I'm not sure I want to continue
with this pregnancy." What is the nurse's best response?
A. "You should discuss this with your partner before making any decisions."
B. "Tell me more about how you are feeling."
C. "This is a normal feeling that many women experience."
D. "Have you considered talking to a counselor?"
Correct Answer: B
Rationale: This open-ended statement allows the client to express her feelings
without judgment and demonstrates therapeutic communication. It encourages the
patient to explore her ambivalence in a supportive, non-judgmental environment.
3. A patient who is 5'5" and weighed 140 lbs before pregnancy has a BMI of 23.
What is the recommended total weight gain for this patient?
A. 15-20 pounds
B. 28-40 pounds
C. 25-35 pounds
D. 11-20 pounds
Correct Answer: C
Rationale: This patient has a normal prepregnancy BMI (18.5-24.9), so the
recommended weight gain is 25-35 pounds (11.5-16 kg).
4. A patient at 10 weeks gestation reports moderate to severe nausea and
vomiting that occurs throughout the day, not just in the morning. She reports
,losing 4 pounds over the past 3 weeks and has ketones in her urine. The nurse
recognizes these findings are MOST consistent with:
A. Morning sickness—an expected finding in the first trimester
B. Hyperemesis gravidarum
C. Gastroenteritis
D. Normal pregnancy with dehydration
Correct Answer: B
Rationale: Hyperemesis gravidarum is characterized by severe, persistent nausea
and vomiting that extends beyond the first trimester, with weight loss exceeding 5%
of prepregnancy weight, dehydration, and ketonuria. This extends beyond typical
morning sickness and requires medical intervention.
5. What is the purpose of alphafetoprotein (AFP) screening at 16 weeks'
gestation?
A. To determine fetal gender
B. To screen for neural tube defects and chromosomal abnormalities
C. To assess fetal lung maturity
D. To evaluate placental function
Correct Answer: B
Rationale: AFP screening at 16-18 weeks gestation is a maternal serum marker
used to screen for neural tube defects (elevated AFP) and chromosomal
abnormalities such as Down syndrome (low AFP). It is a screening tool, not
diagnostic.
, 6. A patient in her third trimester complains of feeling faint, dizzy, and agitated
during vital sign assessment. The nurse should:
A. Have the patient stand up and retake her blood pressure
B. Have the patient sit down and hold her arm in a dependent position
C. Place the patient in a left lateral position
D. Instruct the patient to take deep breaths
Correct Answer: C
Rationale: In the third trimester, the gravid uterus can compress the inferior vena
cava when the patient is supine, causing supine hypotensive syndrome. Placing the
patient in a left lateral position relieves pressure on the vena cava, improves venous
return, and alleviates symptoms of dizziness and agitation.
7. Naegele's Rule is used to calculate:
A. Estimated date of delivery (EDD)
B. Fetal heart rate
C. Fundal height
D. Gestational age
Correct Answer: A
Rationale: Naegele's Rule calculates the estimated date of delivery (EDD) by taking
the first day of the last menstrual period (LMP), subtracting 3 months, adding 7
days, and adding 1 year. It assumes a 28-day menstrual cycle with ovulation on day
14.
(Latest ): Maternal
Child Nursing - Rasmussen
1. A primigravida at 32 weeks gestation presents for a routine prenatal visit.
Fundal height measurement is 28 cm. The nurse reviews the chart and notes
that at the 28-week visit, fundal height was 26 cm. Fetal heart rate is 142 bpm.
The patient reports feeling fetal movement daily. What is the PRIORITY nursing
action?
A. Prepare the patient for an immediate cesarean section
B. Notify the healthcare provider of the fundal height discrepancy and prepare for
further evaluation, such as ultrasound
C. Reassure the patient that fundal height measurements can vary and continue
routine care
D. Instruct the patient to increase caloric intake to promote fetal growth
Correct Answer: B
Rationale: Fundal height measurement is a screening tool for fetal growth. Between
20-34 weeks gestation, fundal height in centimeters should approximate
gestational age in weeks (±2-3 cm). This patient's fundal height at 32 weeks is 28
cm—a discrepancy of 4 cm, which exceeds the acceptable 2-3 cm variance.
Additionally, the fundal height has only increased 2 cm over 4 weeks, which is less
than the expected increase of approximately 1 cm per week. This may indicate
intrauterine growth restriction (IUGR), oligohydramnios, or incorrect dating,
requiring further evaluation with ultrasound.
,2. A client at 8 weeks gestation tells the nurse, "I'm not sure I want to continue
with this pregnancy." What is the nurse's best response?
A. "You should discuss this with your partner before making any decisions."
B. "Tell me more about how you are feeling."
C. "This is a normal feeling that many women experience."
D. "Have you considered talking to a counselor?"
Correct Answer: B
Rationale: This open-ended statement allows the client to express her feelings
without judgment and demonstrates therapeutic communication. It encourages the
patient to explore her ambivalence in a supportive, non-judgmental environment.
3. A patient who is 5'5" and weighed 140 lbs before pregnancy has a BMI of 23.
What is the recommended total weight gain for this patient?
A. 15-20 pounds
B. 28-40 pounds
C. 25-35 pounds
D. 11-20 pounds
Correct Answer: C
Rationale: This patient has a normal prepregnancy BMI (18.5-24.9), so the
recommended weight gain is 25-35 pounds (11.5-16 kg).
4. A patient at 10 weeks gestation reports moderate to severe nausea and
vomiting that occurs throughout the day, not just in the morning. She reports
,losing 4 pounds over the past 3 weeks and has ketones in her urine. The nurse
recognizes these findings are MOST consistent with:
A. Morning sickness—an expected finding in the first trimester
B. Hyperemesis gravidarum
C. Gastroenteritis
D. Normal pregnancy with dehydration
Correct Answer: B
Rationale: Hyperemesis gravidarum is characterized by severe, persistent nausea
and vomiting that extends beyond the first trimester, with weight loss exceeding 5%
of prepregnancy weight, dehydration, and ketonuria. This extends beyond typical
morning sickness and requires medical intervention.
5. What is the purpose of alphafetoprotein (AFP) screening at 16 weeks'
gestation?
A. To determine fetal gender
B. To screen for neural tube defects and chromosomal abnormalities
C. To assess fetal lung maturity
D. To evaluate placental function
Correct Answer: B
Rationale: AFP screening at 16-18 weeks gestation is a maternal serum marker
used to screen for neural tube defects (elevated AFP) and chromosomal
abnormalities such as Down syndrome (low AFP). It is a screening tool, not
diagnostic.
, 6. A patient in her third trimester complains of feeling faint, dizzy, and agitated
during vital sign assessment. The nurse should:
A. Have the patient stand up and retake her blood pressure
B. Have the patient sit down and hold her arm in a dependent position
C. Place the patient in a left lateral position
D. Instruct the patient to take deep breaths
Correct Answer: C
Rationale: In the third trimester, the gravid uterus can compress the inferior vena
cava when the patient is supine, causing supine hypotensive syndrome. Placing the
patient in a left lateral position relieves pressure on the vena cava, improves venous
return, and alleviates symptoms of dizziness and agitation.
7. Naegele's Rule is used to calculate:
A. Estimated date of delivery (EDD)
B. Fetal heart rate
C. Fundal height
D. Gestational age
Correct Answer: A
Rationale: Naegele's Rule calculates the estimated date of delivery (EDD) by taking
the first day of the last menstrual period (LMP), subtracting 3 months, adding 7
days, and adding 1 year. It assumes a 28-day menstrual cycle with ovulation on day
14.
