NUR 2633/NUR2633 Exam 3 V2 | Maternal Child
Health Nursing Q&A with Rationale | Rasmussen
University
1. A nurse is caring for a client in the active phase of labor who is receiving oxytocin (Pitocin).
The nurse notes fetal heart rate (FHR) decelerations that begin after the peak of the
contraction and return to baseline after the contraction ends. Which action is the priority?
A. Increase the oxytocin infusion rate.
B. Discontinue the oxytocin infusion.
C. Place the client in a supine position.
D. Document the finding as a normal occurrence.
Correct Answer: B
Explanation: Late decelerations are indicative of uteroplacental insufficiency, which poses
a significant risk to fetal oxygenation. Discontinuing oxytocin is the priority nursing
intervention to reduce uterine activity and improve blood flow to the placenta. The nurse
must also administer oxygen via non-rebreather mask and notify the healthcare provider
immediately.
2. A postpartum client is diagnosed with a boggy uterus 2 hours after delivery. Which of the
following is the nurse’s first action?
A. Administer methylergonovine (Methergine) IM.
B. Notify the physician of potential hemorrhage.
,C. Catheterize the client to empty the bladder.
D. Perform fundal massage until firm.
Correct Answer: D
Explanation: Fundal massage is the immediate first-line intervention for uterine atony,
which is the primary cause of postpartum hemorrhage. Massaging the fundus stimulates
uterine contractions to compress bleeding vessels at the placental site. If the uterus
becomes firm but then bogs down again, the nurse should then assess for bladder
distention.
3. A nurse is monitoring a client receiving magnesium sulfate for preeclampsia. Which finding
should the nurse report to the provider as a sign of toxicity?
A. Deep tendon reflexes of 2+.
B. Urine output of 40 mL per hour.
C. Respiratory rate of 10 breaths per minute.
D. Blood pressure of 140/90 mmHg.
Correct Answer: C
Explanation: Magnesium sulfate toxicity is a life-threatening complication characterized
by respiratory depression and loss of deep tendon reflexes. A respiratory rate below 12
breaths per minute is a critical indicator of toxicity requiring immediate cessation of the
infusion. The nurse should also have calcium gluconate readily available as the
pharmacological antidote.
, 4. Which clinical manifestation is considered a classic sign of abruptio placentae?
A. Painless, bright red vaginal bleeding.
B. Soft, non-tender abdomen.
C. Fetal heart rate within normal limits.
D. Board-like, rigid abdomen with severe pain.
Correct Answer: D
Explanation: Abruptio placentae involves the premature separation of the placenta from
the uterine wall, leading to internal or external bleeding. This condition typically presents
with sudden-onset, intense abdominal pain and a board-like rigidity of the uterus. This is a
medical emergency that can lead to maternal shock and fetal distress.
5. A newborn’s Apgar score at 1 minute is 8, and at 5 minutes is 9. The nurse understands that
this score indicates which of the following?
A. Severe distress requiring resuscitation.
B. A normal transition with minimal difficulty.
C. Moderate difficulty transitioning to extrauterine life.
D. The need for immediate admission to the NICU.
Correct Answer: B
Explanation: Apgar scores between 7 and 10 are considered normal and indicate that the
newborn is adjusting well to life outside the womb. These scores assess heart rate,
Health Nursing Q&A with Rationale | Rasmussen
University
1. A nurse is caring for a client in the active phase of labor who is receiving oxytocin (Pitocin).
The nurse notes fetal heart rate (FHR) decelerations that begin after the peak of the
contraction and return to baseline after the contraction ends. Which action is the priority?
A. Increase the oxytocin infusion rate.
B. Discontinue the oxytocin infusion.
C. Place the client in a supine position.
D. Document the finding as a normal occurrence.
Correct Answer: B
Explanation: Late decelerations are indicative of uteroplacental insufficiency, which poses
a significant risk to fetal oxygenation. Discontinuing oxytocin is the priority nursing
intervention to reduce uterine activity and improve blood flow to the placenta. The nurse
must also administer oxygen via non-rebreather mask and notify the healthcare provider
immediately.
2. A postpartum client is diagnosed with a boggy uterus 2 hours after delivery. Which of the
following is the nurse’s first action?
A. Administer methylergonovine (Methergine) IM.
B. Notify the physician of potential hemorrhage.
,C. Catheterize the client to empty the bladder.
D. Perform fundal massage until firm.
Correct Answer: D
Explanation: Fundal massage is the immediate first-line intervention for uterine atony,
which is the primary cause of postpartum hemorrhage. Massaging the fundus stimulates
uterine contractions to compress bleeding vessels at the placental site. If the uterus
becomes firm but then bogs down again, the nurse should then assess for bladder
distention.
3. A nurse is monitoring a client receiving magnesium sulfate for preeclampsia. Which finding
should the nurse report to the provider as a sign of toxicity?
A. Deep tendon reflexes of 2+.
B. Urine output of 40 mL per hour.
C. Respiratory rate of 10 breaths per minute.
D. Blood pressure of 140/90 mmHg.
Correct Answer: C
Explanation: Magnesium sulfate toxicity is a life-threatening complication characterized
by respiratory depression and loss of deep tendon reflexes. A respiratory rate below 12
breaths per minute is a critical indicator of toxicity requiring immediate cessation of the
infusion. The nurse should also have calcium gluconate readily available as the
pharmacological antidote.
, 4. Which clinical manifestation is considered a classic sign of abruptio placentae?
A. Painless, bright red vaginal bleeding.
B. Soft, non-tender abdomen.
C. Fetal heart rate within normal limits.
D. Board-like, rigid abdomen with severe pain.
Correct Answer: D
Explanation: Abruptio placentae involves the premature separation of the placenta from
the uterine wall, leading to internal or external bleeding. This condition typically presents
with sudden-onset, intense abdominal pain and a board-like rigidity of the uterus. This is a
medical emergency that can lead to maternal shock and fetal distress.
5. A newborn’s Apgar score at 1 minute is 8, and at 5 minutes is 9. The nurse understands that
this score indicates which of the following?
A. Severe distress requiring resuscitation.
B. A normal transition with minimal difficulty.
C. Moderate difficulty transitioning to extrauterine life.
D. The need for immediate admission to the NICU.
Correct Answer: B
Explanation: Apgar scores between 7 and 10 are considered normal and indicate that the
newborn is adjusting well to life outside the womb. These scores assess heart rate,
