NUR 2633/NUR2633 Exam 3 V1 | Maternal Child
Health Nursing Q&A with Rationale | Rasmussen
University
1. A nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. Which of
the following findings should the nurse identify as a priority to report to the provider?
A. Urinary output of 40 mL/hr
B. Deep tendon reflexes of 2+
C. Blood pressure of 150/95 mmHg
D. Respiratory rate of 10/min
Correct Answer: D
Explanation: A respiratory rate of 10/min is a sign of magnesium toxicity, as the
medication is a central nervous system depressant. The nurse must prioritize monitoring
the respiratory status and deep tendon reflexes to ensure client safety. Immediate
intervention includes stopping the infusion and preparing the antidote, calcium gluconate.
2. A nurse is monitoring a client in labor and observes late decelerations on the fetal heart
rate monitor. Which of the following actions should the nurse take first?
A. Assist the client into a side-lying position
B. Perform a vaginal examination to check for cord prolapse
C. Increase the rate of the maintenance IV fluid
,D. Administer oxygen via a nonrebreather face mask
Correct Answer: A
Explanation: Late decelerations indicate uteroplacental insufficiency, which is a significant
risk to fetal oxygenation. Positioning the client on their side improves blood flow to the
placenta and is the primary nursing intervention. Following this action, the nurse should
also increase fluids and provide oxygen as prescribed.
3. A nurse is assessing a newborn 1 minute after birth and finds a heart rate of 110/min, a
slow/weak cry, some flexion of the extremities, a grimace when suctioned, and a pink body
with blue extremities. What is the Apgar score?
A. 5
B. 8
C. 7
D. 6
Correct Answer: D
Explanation: The score is 6 based on the following: Heart rate > 100 (2), slow cry (1),
some flexion (1), grimace (1), and acrocyanosis (1). The Apgar score helps clinicians
determine if the newborn requires immediate medical attention or resuscitation.
Assessments are typically repeated at 5 minutes to evaluate the infant’s transition.
, 4. A nurse is providing discharge teaching to the parents of a child who has cystic fibrosis.
Which of the following instructions should the nurse include regarding pancreatic enzymes?
A. Give enzymes with every meal and snack
B. Administer enzymes between meals
C. Dissolve the enzymes in a glass of warm milk
D. Skip the dose if the child is not hungry
Correct Answer: A
Explanation: Pancreatic enzymes are necessary to facilitate the digestion and absorption
of fats, proteins, and carbohydrates in children with cystic fibrosis. They must be taken
with every meal and snack to be effective in preventing malabsorption. Failure to provide
these enzymes consistently can lead to steatorrhea and poor weight gain.
5. A nurse is assessing a 2-year-old child for signs of hypertrophic pyloric stenosis. Which of
the following findings should the nurse expect?
A. Weight gain despite frequent emesis
B. Current jelly-like stools
C. Projectile vomiting after feedings
D. Bowel movements every 3 to 4 days
Correct Answer: C
Health Nursing Q&A with Rationale | Rasmussen
University
1. A nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. Which of
the following findings should the nurse identify as a priority to report to the provider?
A. Urinary output of 40 mL/hr
B. Deep tendon reflexes of 2+
C. Blood pressure of 150/95 mmHg
D. Respiratory rate of 10/min
Correct Answer: D
Explanation: A respiratory rate of 10/min is a sign of magnesium toxicity, as the
medication is a central nervous system depressant. The nurse must prioritize monitoring
the respiratory status and deep tendon reflexes to ensure client safety. Immediate
intervention includes stopping the infusion and preparing the antidote, calcium gluconate.
2. A nurse is monitoring a client in labor and observes late decelerations on the fetal heart
rate monitor. Which of the following actions should the nurse take first?
A. Assist the client into a side-lying position
B. Perform a vaginal examination to check for cord prolapse
C. Increase the rate of the maintenance IV fluid
,D. Administer oxygen via a nonrebreather face mask
Correct Answer: A
Explanation: Late decelerations indicate uteroplacental insufficiency, which is a significant
risk to fetal oxygenation. Positioning the client on their side improves blood flow to the
placenta and is the primary nursing intervention. Following this action, the nurse should
also increase fluids and provide oxygen as prescribed.
3. A nurse is assessing a newborn 1 minute after birth and finds a heart rate of 110/min, a
slow/weak cry, some flexion of the extremities, a grimace when suctioned, and a pink body
with blue extremities. What is the Apgar score?
A. 5
B. 8
C. 7
D. 6
Correct Answer: D
Explanation: The score is 6 based on the following: Heart rate > 100 (2), slow cry (1),
some flexion (1), grimace (1), and acrocyanosis (1). The Apgar score helps clinicians
determine if the newborn requires immediate medical attention or resuscitation.
Assessments are typically repeated at 5 minutes to evaluate the infant’s transition.
, 4. A nurse is providing discharge teaching to the parents of a child who has cystic fibrosis.
Which of the following instructions should the nurse include regarding pancreatic enzymes?
A. Give enzymes with every meal and snack
B. Administer enzymes between meals
C. Dissolve the enzymes in a glass of warm milk
D. Skip the dose if the child is not hungry
Correct Answer: A
Explanation: Pancreatic enzymes are necessary to facilitate the digestion and absorption
of fats, proteins, and carbohydrates in children with cystic fibrosis. They must be taken
with every meal and snack to be effective in preventing malabsorption. Failure to provide
these enzymes consistently can lead to steatorrhea and poor weight gain.
5. A nurse is assessing a 2-year-old child for signs of hypertrophic pyloric stenosis. Which of
the following findings should the nurse expect?
A. Weight gain despite frequent emesis
B. Current jelly-like stools
C. Projectile vomiting after feedings
D. Bowel movements every 3 to 4 days
Correct Answer: C
