NR327/NR 327 Exam 2 V2 | Maternal Child Nursing
Q&A with Rationale | Chamberlain University
1. A nurse is monitoring a client in active labor who has an external fetal monitor. The nurse
observes late decelerations on the tracing. Which of the following is the priority nursing
action?
A. Place the client in a side-lying position.
B. Increase the rate of the maintenance IV fluids.
C. Administer oxygen at 2 L/min via nasal cannula.
D. Perform a vaginal examination to check for cord prolapse.
Correct Answer: A
Explanation: Late decelerations are caused by uteroplacental insufficiency and indicate
fetal distress. The first priority is to improve oxygenation and blood flow to the placenta by
repositioning the client to the lateral position. This action relieves pressure on the vena
cava and maximizes uterine blood flow immediately.
2. A nurse is assessing a client who is 2 hours postpartum and identifies a boggy uterus that is
displaced to the right of the midline. Which of the following actions should the nurse take
first?
A. Assist the client to the bathroom to void.
B. Massage the fundus until it becomes firm.
,C. Administer oxytocin 10 units intramuscularly.
D. Notify the provider of the fundal location.
Correct Answer: A
Explanation: A fundus that is displaced to the right and boggy indicates a full bladder,
which prevents the uterus from contracting effectively. Assisting the client to void or
catheterizing them will allow the uterus to return to the midline and contract. While fundal
massage is important, the underlying cause of displacement must be addressed to prevent
hemorrhage.
3. A nurse is caring for a client with preeclampsia who is receiving a magnesium sulfate
infusion. The nurse notes that the client’s respiratory rate is 10/min and deep tendon reflexes
are absent. Which of the following medications should the nurse have available?
A. Naloxone
B. Terbutaline
C. Calcium gluconate
D. Protamine sulfate
Correct Answer: C
Explanation: Absence of deep tendon reflexes and a decreased respiratory rate are signs of
magnesium sulfate toxicity. Calcium gluconate is the specific antidote for magnesium
toxicity and should be kept at the bedside. The nurse must stop the infusion immediately
before administering the antidote to prevent cardiac arrest.
,4. A nurse is assessing a newborn 1 minute after birth. The newborn has a heart rate of
110/min, a weak cry, some flexion of the extremities, grimaces when suctioned, and is pink
with blue extremities. What APGAR score should the nurse assign?
A. 5
B. 8
C. 7
D. 6
Correct Answer: D
Explanation: The APGAR score is calculated based on 2 points for heart rate (over 100), 1
point for respiratory effort (weak cry), 1 point for muscle tone (some flexion), 1 point for
reflex irritability (grimace), and 1 point for color (acrocyanosis). Adding these together
results in a total score of 6. A score of 6 indicates the newborn may need some initial
stabilization and close monitoring.
5. A client at 34 weeks of gestation is in preterm labor. The provider prescribes
betamethasone. The nurse understands this medication is administered for which of the
following purposes?
A. To stop uterine contractions and prolong pregnancy.
B. To increase the client’s blood pressure and placental perfusion.
C. To prevent group B streptococcus infection in the neonate.
D. To promote fetal lung maturity by stimulating surfactant production.
, Correct Answer: D
Explanation: Betamethasone is a corticosteroid given to clients at risk for preterm
delivery to enhance fetal lung development. It stimulates the production of surfactant,
which reduces the incidence of respiratory distress syndrome in preterm infants. The
medication is most effective if delivery is delayed for at least 24 to 48 hours after
administration.
6. A nurse is teaching a postpartum client about breastfeeding. Which of the following
statements by the client indicates an understanding of the teaching?
A. I should wash my nipples with soap before each feeding.
B. I should feed my baby on a strict schedule every 4 hours.
C. I will know my baby is getting enough milk if there are 6 to 8 wet diapers daily.
D. I should offer the baby water between feedings to stay hydrated.
Correct Answer: C
Explanation: Adequate hydration and intake in a breastfed newborn are monitored by the
number of wet diapers, with 6 to 8 being the standard for a well-hydrated infant. Soap
should be avoided on nipples as it can cause drying and cracking. Newborns should be fed
on demand, usually 8 to 12 times in a 24-hour period, rather than on a strict schedule.
7. Which of the following assessments is the priority for a nurse caring for a client who just
received an epidural block for labor pain?
A. Checking the client’s temperature every hour.
Q&A with Rationale | Chamberlain University
1. A nurse is monitoring a client in active labor who has an external fetal monitor. The nurse
observes late decelerations on the tracing. Which of the following is the priority nursing
action?
A. Place the client in a side-lying position.
B. Increase the rate of the maintenance IV fluids.
C. Administer oxygen at 2 L/min via nasal cannula.
D. Perform a vaginal examination to check for cord prolapse.
Correct Answer: A
Explanation: Late decelerations are caused by uteroplacental insufficiency and indicate
fetal distress. The first priority is to improve oxygenation and blood flow to the placenta by
repositioning the client to the lateral position. This action relieves pressure on the vena
cava and maximizes uterine blood flow immediately.
2. A nurse is assessing a client who is 2 hours postpartum and identifies a boggy uterus that is
displaced to the right of the midline. Which of the following actions should the nurse take
first?
A. Assist the client to the bathroom to void.
B. Massage the fundus until it becomes firm.
,C. Administer oxytocin 10 units intramuscularly.
D. Notify the provider of the fundal location.
Correct Answer: A
Explanation: A fundus that is displaced to the right and boggy indicates a full bladder,
which prevents the uterus from contracting effectively. Assisting the client to void or
catheterizing them will allow the uterus to return to the midline and contract. While fundal
massage is important, the underlying cause of displacement must be addressed to prevent
hemorrhage.
3. A nurse is caring for a client with preeclampsia who is receiving a magnesium sulfate
infusion. The nurse notes that the client’s respiratory rate is 10/min and deep tendon reflexes
are absent. Which of the following medications should the nurse have available?
A. Naloxone
B. Terbutaline
C. Calcium gluconate
D. Protamine sulfate
Correct Answer: C
Explanation: Absence of deep tendon reflexes and a decreased respiratory rate are signs of
magnesium sulfate toxicity. Calcium gluconate is the specific antidote for magnesium
toxicity and should be kept at the bedside. The nurse must stop the infusion immediately
before administering the antidote to prevent cardiac arrest.
,4. A nurse is assessing a newborn 1 minute after birth. The newborn has a heart rate of
110/min, a weak cry, some flexion of the extremities, grimaces when suctioned, and is pink
with blue extremities. What APGAR score should the nurse assign?
A. 5
B. 8
C. 7
D. 6
Correct Answer: D
Explanation: The APGAR score is calculated based on 2 points for heart rate (over 100), 1
point for respiratory effort (weak cry), 1 point for muscle tone (some flexion), 1 point for
reflex irritability (grimace), and 1 point for color (acrocyanosis). Adding these together
results in a total score of 6. A score of 6 indicates the newborn may need some initial
stabilization and close monitoring.
5. A client at 34 weeks of gestation is in preterm labor. The provider prescribes
betamethasone. The nurse understands this medication is administered for which of the
following purposes?
A. To stop uterine contractions and prolong pregnancy.
B. To increase the client’s blood pressure and placental perfusion.
C. To prevent group B streptococcus infection in the neonate.
D. To promote fetal lung maturity by stimulating surfactant production.
, Correct Answer: D
Explanation: Betamethasone is a corticosteroid given to clients at risk for preterm
delivery to enhance fetal lung development. It stimulates the production of surfactant,
which reduces the incidence of respiratory distress syndrome in preterm infants. The
medication is most effective if delivery is delayed for at least 24 to 48 hours after
administration.
6. A nurse is teaching a postpartum client about breastfeeding. Which of the following
statements by the client indicates an understanding of the teaching?
A. I should wash my nipples with soap before each feeding.
B. I should feed my baby on a strict schedule every 4 hours.
C. I will know my baby is getting enough milk if there are 6 to 8 wet diapers daily.
D. I should offer the baby water between feedings to stay hydrated.
Correct Answer: C
Explanation: Adequate hydration and intake in a breastfed newborn are monitored by the
number of wet diapers, with 6 to 8 being the standard for a well-hydrated infant. Soap
should be avoided on nipples as it can cause drying and cracking. Newborns should be fed
on demand, usually 8 to 12 times in a 24-hour period, rather than on a strict schedule.
7. Which of the following assessments is the priority for a nurse caring for a client who just
received an epidural block for labor pain?
A. Checking the client’s temperature every hour.
