NR327/NR 327 Exam 1 V3 | Maternal Child Nursing
Q&A with Rationale | Chamberlain University
1. A nurse is performing an assessment on a client who is at 38 weeks of gestation. The client
reports a sudden gush of fluid from the vagina. Which of the following is the priority nursing
action?
A. Check the pH of the fluid with Nitrazine paper.
B. Assess the fetal heart rate (FHR).
C. Perform a sterile vaginal examination.
D. Notify the provider immediately.
Correct Answer: B
Explanation: When the membranes rupture, the primary concern is the potential for
umbilical cord prolapse, which can compromise fetal oxygenation. The nurse must
immediately assess the FHR to ensure the baby is not in distress. Following this
assessment, the nurse can verify the rupture of membranes and document the color and
odor of the fluid.
2. A nurse is caring for a client who is in the first stage of labor. The nurse observes a pattern
of variable decelerations on the fetal monitor strip. Which of the following actions should the
nurse take first?
A. Administer oxygen via nonrebreather mask.
,B. Change the client’s position.
C. Increase the IV fluid rate.
D. Prepare for an emergency cesarean birth.
Correct Answer: B
Explanation: Variable decelerations are typically indicative of umbilical cord compression.
The first intervention for cord compression is to change the maternal position to relieve
the pressure on the cord. This simple nursing action often resolves the deceleration and
restores fetal well-being without further intervention.
3. A nurse is reviewing the laboratory results for a client who is at 28 weeks of gestation and
has an O-negative blood type. The indirect Coombs’ test is negative. Which of the following
actions should the nurse expect?
A. Administer Rho(D) immune globulin within 72 hours.
B. Perform an amniocentesis for bilirubin levels.
C. Monitor for signs of fetal hydrops.
D. Administer Rho(D) immune globulin now.
Correct Answer: D
Explanation: Rho(D) immune globulin is administered at 28 weeks of gestation to all Rh-
negative women who are not sensitized (negative Coombs’ test). This prevents the mother
,from forming antibodies against the Rh factor if she is exposed to Rh-positive fetal blood.
The treatment will be repeated after delivery if the newborn is confirmed to be Rh-positive.
4. A nurse is assessing a client who is 2 hours postpartum and has a boggy fundus that is
deviated to the right. Which of the following actions should the nurse take first?
A. Massage the fundus until firm.
B. Increase the IV fluid rate.
C. Administer oxytocin as prescribed.
D. Assist the client to the bathroom to void.
Correct Answer: D
Explanation: A fundus that is deviated to the right and boggy typically indicates a
distended bladder. A full bladder displaces the uterus and prevents it from contracting
effectively, increasing the risk of hemorrhage. The nurse should assist the client to void to
empty the bladder and then reassess the fundal tone.
5. A client is at 32 weeks of gestation and is admitted for preterm labor. The provider
prescribes magnesium sulfate IV. The nurse should monitor for which of the following signs of
magnesium toxicity?
A. Increased deep tendon reflexes.
B. Tachycardia and hypertension.
C. Respiratory rate less than 12 breaths per minute.
, D. Hyperactivity and insomnia.
Correct Answer: C
Explanation: Magnesium sulfate is a CNS depressant used to stop contractions or prevent
seizures in preeclampsia. Signs of toxicity include respiratory depression (rate <12/min),
loss of deep tendon reflexes, and decreased urinary output. The nurse must monitor these
signs closely and have calcium gluconate available as the antidote.
6. A nurse is teaching a group of parents about newborn safety. Which of the following
instructions should the nurse include regarding SIDS prevention?
A. Place the newborn on their side for sleep.
B. Use soft bedding and pillows in the crib.
C. Place the newborn in the supine position to sleep.
D. Keep the newborn’s room temperature very warm.
Correct Answer: C
Explanation: The ‘Back to Sleep’ campaign recommends placing all newborns in the supine
(back) position for sleeping to reduce the risk of Sudden Infant Death Syndrome (SIDS).
Side-sleeping is no longer recommended as the infant can easily roll onto their stomach. A
firm sleep surface without soft objects or loose bedding is essential for safety.
7. A nurse is assessing a newborn 1 hour after birth. Which of the following findings should
the nurse report to the provider?
A. Acrocyanosis of the hands and feet.
Q&A with Rationale | Chamberlain University
1. A nurse is performing an assessment on a client who is at 38 weeks of gestation. The client
reports a sudden gush of fluid from the vagina. Which of the following is the priority nursing
action?
A. Check the pH of the fluid with Nitrazine paper.
B. Assess the fetal heart rate (FHR).
C. Perform a sterile vaginal examination.
D. Notify the provider immediately.
Correct Answer: B
Explanation: When the membranes rupture, the primary concern is the potential for
umbilical cord prolapse, which can compromise fetal oxygenation. The nurse must
immediately assess the FHR to ensure the baby is not in distress. Following this
assessment, the nurse can verify the rupture of membranes and document the color and
odor of the fluid.
2. A nurse is caring for a client who is in the first stage of labor. The nurse observes a pattern
of variable decelerations on the fetal monitor strip. Which of the following actions should the
nurse take first?
A. Administer oxygen via nonrebreather mask.
,B. Change the client’s position.
C. Increase the IV fluid rate.
D. Prepare for an emergency cesarean birth.
Correct Answer: B
Explanation: Variable decelerations are typically indicative of umbilical cord compression.
The first intervention for cord compression is to change the maternal position to relieve
the pressure on the cord. This simple nursing action often resolves the deceleration and
restores fetal well-being without further intervention.
3. A nurse is reviewing the laboratory results for a client who is at 28 weeks of gestation and
has an O-negative blood type. The indirect Coombs’ test is negative. Which of the following
actions should the nurse expect?
A. Administer Rho(D) immune globulin within 72 hours.
B. Perform an amniocentesis for bilirubin levels.
C. Monitor for signs of fetal hydrops.
D. Administer Rho(D) immune globulin now.
Correct Answer: D
Explanation: Rho(D) immune globulin is administered at 28 weeks of gestation to all Rh-
negative women who are not sensitized (negative Coombs’ test). This prevents the mother
,from forming antibodies against the Rh factor if she is exposed to Rh-positive fetal blood.
The treatment will be repeated after delivery if the newborn is confirmed to be Rh-positive.
4. A nurse is assessing a client who is 2 hours postpartum and has a boggy fundus that is
deviated to the right. Which of the following actions should the nurse take first?
A. Massage the fundus until firm.
B. Increase the IV fluid rate.
C. Administer oxytocin as prescribed.
D. Assist the client to the bathroom to void.
Correct Answer: D
Explanation: A fundus that is deviated to the right and boggy typically indicates a
distended bladder. A full bladder displaces the uterus and prevents it from contracting
effectively, increasing the risk of hemorrhage. The nurse should assist the client to void to
empty the bladder and then reassess the fundal tone.
5. A client is at 32 weeks of gestation and is admitted for preterm labor. The provider
prescribes magnesium sulfate IV. The nurse should monitor for which of the following signs of
magnesium toxicity?
A. Increased deep tendon reflexes.
B. Tachycardia and hypertension.
C. Respiratory rate less than 12 breaths per minute.
, D. Hyperactivity and insomnia.
Correct Answer: C
Explanation: Magnesium sulfate is a CNS depressant used to stop contractions or prevent
seizures in preeclampsia. Signs of toxicity include respiratory depression (rate <12/min),
loss of deep tendon reflexes, and decreased urinary output. The nurse must monitor these
signs closely and have calcium gluconate available as the antidote.
6. A nurse is teaching a group of parents about newborn safety. Which of the following
instructions should the nurse include regarding SIDS prevention?
A. Place the newborn on their side for sleep.
B. Use soft bedding and pillows in the crib.
C. Place the newborn in the supine position to sleep.
D. Keep the newborn’s room temperature very warm.
Correct Answer: C
Explanation: The ‘Back to Sleep’ campaign recommends placing all newborns in the supine
(back) position for sleeping to reduce the risk of Sudden Infant Death Syndrome (SIDS).
Side-sleeping is no longer recommended as the infant can easily roll onto their stomach. A
firm sleep surface without soft objects or loose bedding is essential for safety.
7. A nurse is assessing a newborn 1 hour after birth. Which of the following findings should
the nurse report to the provider?
A. Acrocyanosis of the hands and feet.
