NR327/NR 327 Exam 3 V2 | Maternal Child Nursing
Q&A with Rationale | Chamberlain University
1. A nurse is caring for a client who is at 34 weeks of gestation and has a prescription for
magnesium sulfate IV to treat preeclampsia. Which of the following findings should the nurse
identify as a priority to report to the provider?
A. Deep tendon reflexes of 2+
B. Generalized pruritus
C. Respiratory rate of 14 breaths/min
D. Urinary output of 20 mL/hr
Correct Answer: D
Explanation: A urinary output of less than 30 mL/hr is a critical indicator of magnesium
sulfate toxicity because the drug is excreted primarily through the kidneys. When urine
output decreases, the risk for toxic levels of magnesium increases significantly. The nurse
must prioritize monitoring renal function to prevent respiratory depression or cardiac
arrest.
2. A nurse is assessing a client who is 12 hours postpartum. The nurse notes that the client’s
fundus is deviated to the right and is two fingerbreadths above the umbilicus. Which of the
following actions should the nurse take?
A. Assist the client to empty her bladder
,B. Administer oxytocin intramuscularly
C. Massage the fundus until firm
D. Place the client in a Trendelenburg position
Correct Answer: A
Explanation: A fundus that is deviated from the midline and elevated is a classic sign of
bladder distention. A full bladder displaces the uterus, preventing it from contracting
effectively and increasing the risk of postpartum hemorrhage. Assisting the client to void is
the most appropriate immediate intervention.
3. During a routine prenatal visit at 32 weeks, a client asks why she needs to perform daily
fetal movement counts. Which response by the nurse is most appropriate?
A. It helps determine if the baby is in a breech position.
B. It allows us to predict the exact date of your labor onset.
C. It is a non-invasive way to monitor fetal well-being and oxygenation.
D. It is required for all patients to prevent gestational diabetes.
Correct Answer: C
Explanation: Fetal movement counts, often called kick counts, serve as a primary
screening tool for fetal hypoxia or distress. A decrease in movement may indicate that the
fetus is not receiving adequate oxygen through the placenta. Teaching the client to monitor
these movements empowers her to seek care early if changes occur.
,4. A nurse is assessing a newborn 1 hour after birth. Which of the following respiratory
findings should the nurse report to the provider as a sign of respiratory distress?
A. Nasal flaring
B. Acrocyanosis
C. Irregular respirations
D. Respirations of 50 breaths/min
Correct Answer: A
Explanation: Nasal flaring is a compensatory mechanism used by newborns to increase
the volume of air inspired during respiratory distress. While acrocyanosis and irregular
breathing are common in the first few hours of life, flaring indicates increased work of
breathing. The nurse must assess for other signs like grunting or retractions.
5. A nurse is caring for a client who is in active labor and receives an epidural block. The nurse
should prioritize monitoring for which of the following adverse effects?
A. Maternal hypertension
B. Maternal hypotension
C. Fetal tachycardia
D. Increased urinary output
Correct Answer: B
, Explanation: Maternal hypotension is the most common side effect of epidural anesthesia
due to the blockade of sympathetic nerves and subsequent vasodilation. This drop in blood
pressure can lead to decreased placental perfusion and fetal bradycardia. Nursing care
involves pre-loading the client with IV fluids and frequent blood pressure checks.
6. A client at 38 weeks gestation presents with painless, bright red vaginal bleeding. Which of
the following conditions should the nurse suspect?
A. Abruptio placentae
B. Rupture of the uterus
C. Placenta previa
D. Ectopic pregnancy
Correct Answer: C
Explanation: Placenta previa is characterized by the implantation of the placenta over the
cervical os, resulting in painless bright red bleeding as the cervix begins to dilate. In
contrast, abruptio placentae typically involves painful, dark red bleeding and uterine
rigidity. It is critical to avoid vaginal exams in patients with suspected previa until an
ultrasound is performed.
7. A nurse is teaching a postpartum client about breastfeeding. Which statement by the client
indicates an understanding of how to prevent nipple soreness?
A. I will apply alcohol to my nipples after each feeding.
B. I will use a pacifier between feedings to toughen my nipples.
Q&A with Rationale | Chamberlain University
1. A nurse is caring for a client who is at 34 weeks of gestation and has a prescription for
magnesium sulfate IV to treat preeclampsia. Which of the following findings should the nurse
identify as a priority to report to the provider?
A. Deep tendon reflexes of 2+
B. Generalized pruritus
C. Respiratory rate of 14 breaths/min
D. Urinary output of 20 mL/hr
Correct Answer: D
Explanation: A urinary output of less than 30 mL/hr is a critical indicator of magnesium
sulfate toxicity because the drug is excreted primarily through the kidneys. When urine
output decreases, the risk for toxic levels of magnesium increases significantly. The nurse
must prioritize monitoring renal function to prevent respiratory depression or cardiac
arrest.
2. A nurse is assessing a client who is 12 hours postpartum. The nurse notes that the client’s
fundus is deviated to the right and is two fingerbreadths above the umbilicus. Which of the
following actions should the nurse take?
A. Assist the client to empty her bladder
,B. Administer oxytocin intramuscularly
C. Massage the fundus until firm
D. Place the client in a Trendelenburg position
Correct Answer: A
Explanation: A fundus that is deviated from the midline and elevated is a classic sign of
bladder distention. A full bladder displaces the uterus, preventing it from contracting
effectively and increasing the risk of postpartum hemorrhage. Assisting the client to void is
the most appropriate immediate intervention.
3. During a routine prenatal visit at 32 weeks, a client asks why she needs to perform daily
fetal movement counts. Which response by the nurse is most appropriate?
A. It helps determine if the baby is in a breech position.
B. It allows us to predict the exact date of your labor onset.
C. It is a non-invasive way to monitor fetal well-being and oxygenation.
D. It is required for all patients to prevent gestational diabetes.
Correct Answer: C
Explanation: Fetal movement counts, often called kick counts, serve as a primary
screening tool for fetal hypoxia or distress. A decrease in movement may indicate that the
fetus is not receiving adequate oxygen through the placenta. Teaching the client to monitor
these movements empowers her to seek care early if changes occur.
,4. A nurse is assessing a newborn 1 hour after birth. Which of the following respiratory
findings should the nurse report to the provider as a sign of respiratory distress?
A. Nasal flaring
B. Acrocyanosis
C. Irregular respirations
D. Respirations of 50 breaths/min
Correct Answer: A
Explanation: Nasal flaring is a compensatory mechanism used by newborns to increase
the volume of air inspired during respiratory distress. While acrocyanosis and irregular
breathing are common in the first few hours of life, flaring indicates increased work of
breathing. The nurse must assess for other signs like grunting or retractions.
5. A nurse is caring for a client who is in active labor and receives an epidural block. The nurse
should prioritize monitoring for which of the following adverse effects?
A. Maternal hypertension
B. Maternal hypotension
C. Fetal tachycardia
D. Increased urinary output
Correct Answer: B
, Explanation: Maternal hypotension is the most common side effect of epidural anesthesia
due to the blockade of sympathetic nerves and subsequent vasodilation. This drop in blood
pressure can lead to decreased placental perfusion and fetal bradycardia. Nursing care
involves pre-loading the client with IV fluids and frequent blood pressure checks.
6. A client at 38 weeks gestation presents with painless, bright red vaginal bleeding. Which of
the following conditions should the nurse suspect?
A. Abruptio placentae
B. Rupture of the uterus
C. Placenta previa
D. Ectopic pregnancy
Correct Answer: C
Explanation: Placenta previa is characterized by the implantation of the placenta over the
cervical os, resulting in painless bright red bleeding as the cervix begins to dilate. In
contrast, abruptio placentae typically involves painful, dark red bleeding and uterine
rigidity. It is critical to avoid vaginal exams in patients with suspected previa until an
ultrasound is performed.
7. A nurse is teaching a postpartum client about breastfeeding. Which statement by the client
indicates an understanding of how to prevent nipple soreness?
A. I will apply alcohol to my nipples after each feeding.
B. I will use a pacifier between feedings to toughen my nipples.
