NUR 2633/NUR2633 Exam 4 V1 | Maternal Child
Health Nursing Q&A with Rationale | Rasmussen
University
1. A nurse is monitoring a client who is receiving Magnesium Sulfate for preeclampsia. The
nurse notes the client’s deep tendon reflexes (DTRs) are absent and the respiratory rate is 10
breaths/minute. What is the priority nursing action?
A. Administer Calcium Gluconate IV push.
B. Increase the IV fluid rate to flush the medication.
C. Place the client in a Trendelenburg position.
D. Check the client’s blood pressure immediately.
Correct Answer: A
Explanation: Absent deep tendon reflexes and a decreased respiratory rate are classic
signs of magnesium toxicity. The nurse must immediately stop the infusion and administer
the antagonist, Calcium Gluconate. This intervention is critical to prevent respiratory arrest
and cardiac collapse in the patient.
2. A laboring client’s fetal heart rate (FHR) monitor shows late decelerations. Which of the
following is the nurse’s first priority?
A. Perform a vaginal exam to check for cord prolapse.
B. Turn the client to a side-lying position.
,C. Prepare the client for an immediate Cesarean section.
D. Administer an IV bolus of Lactated Ringer’s.
Correct Answer: B
Explanation: Late decelerations are indicative of uteroplacental insufficiency, which can
lead to fetal hypoxia. Repositioning the mother to a side-lying position helps improve blood
flow to the placenta by relieving pressure on the vena cava. This is the initial step in the
intrauterine resuscitation protocol before considering more invasive measures.
3. The nurse is assessing a client 2 hours postpartum and finds the fundus is boggy and
displaced to the right. What is the most likely cause of this finding?
A. Retained placental fragments.
B. Uterine atony due to exhaustion.
C. Bladder distension.
D. Internal cervical lacerations.
Correct Answer: C
Explanation: A displaced fundus, especially to the right, is a hallmark sign of a full bladder
in the postpartum period. A distended bladder prevents the uterus from contracting
effectively, which increases the risk of hemorrhage. The nurse should assist the client to
void or catheterize if necessary to allow the fundus to return to the midline and firm up.
, 4. A client at 32 weeks gestation is admitted in preterm labor. The provider orders
Betamethasone 12 mg IM. What is the primary purpose of this medication?
A. To promote fetal lung maturity by increasing surfactant production.
B. To prevent maternal infection during labor.
C. To stop uterine contractions and delay delivery.
D. To increase maternal blood volume for placental perfusion.
Correct Answer: A
Explanation: Betamethasone is a corticosteroid administered to women in preterm labor
to accelerate fetal lung development. It stimulates the production of surfactant, which
reduces the risk of Respiratory Distress Syndrome (RDS) in the neonate. This medication is
typically given in two doses, 24 hours apart, for maximum effectiveness.
5. Which clinical finding is most characteristic of Placenta Previa?
A. Severe abdominal pain with a board-like abdomen.
B. Sudden drop in blood pressure without visible bleeding.
C. Intermittent lower back pain with dark red spotting.
D. Painless, bright red vaginal bleeding in the third trimester.
Correct Answer: D
Explanation: Placenta previa occurs when the placenta covers the cervical os, leading to
painless, bright red bleeding as the cervix begins to dilate. Unlike abruptio placentae, there
Health Nursing Q&A with Rationale | Rasmussen
University
1. A nurse is monitoring a client who is receiving Magnesium Sulfate for preeclampsia. The
nurse notes the client’s deep tendon reflexes (DTRs) are absent and the respiratory rate is 10
breaths/minute. What is the priority nursing action?
A. Administer Calcium Gluconate IV push.
B. Increase the IV fluid rate to flush the medication.
C. Place the client in a Trendelenburg position.
D. Check the client’s blood pressure immediately.
Correct Answer: A
Explanation: Absent deep tendon reflexes and a decreased respiratory rate are classic
signs of magnesium toxicity. The nurse must immediately stop the infusion and administer
the antagonist, Calcium Gluconate. This intervention is critical to prevent respiratory arrest
and cardiac collapse in the patient.
2. A laboring client’s fetal heart rate (FHR) monitor shows late decelerations. Which of the
following is the nurse’s first priority?
A. Perform a vaginal exam to check for cord prolapse.
B. Turn the client to a side-lying position.
,C. Prepare the client for an immediate Cesarean section.
D. Administer an IV bolus of Lactated Ringer’s.
Correct Answer: B
Explanation: Late decelerations are indicative of uteroplacental insufficiency, which can
lead to fetal hypoxia. Repositioning the mother to a side-lying position helps improve blood
flow to the placenta by relieving pressure on the vena cava. This is the initial step in the
intrauterine resuscitation protocol before considering more invasive measures.
3. The nurse is assessing a client 2 hours postpartum and finds the fundus is boggy and
displaced to the right. What is the most likely cause of this finding?
A. Retained placental fragments.
B. Uterine atony due to exhaustion.
C. Bladder distension.
D. Internal cervical lacerations.
Correct Answer: C
Explanation: A displaced fundus, especially to the right, is a hallmark sign of a full bladder
in the postpartum period. A distended bladder prevents the uterus from contracting
effectively, which increases the risk of hemorrhage. The nurse should assist the client to
void or catheterize if necessary to allow the fundus to return to the midline and firm up.
, 4. A client at 32 weeks gestation is admitted in preterm labor. The provider orders
Betamethasone 12 mg IM. What is the primary purpose of this medication?
A. To promote fetal lung maturity by increasing surfactant production.
B. To prevent maternal infection during labor.
C. To stop uterine contractions and delay delivery.
D. To increase maternal blood volume for placental perfusion.
Correct Answer: A
Explanation: Betamethasone is a corticosteroid administered to women in preterm labor
to accelerate fetal lung development. It stimulates the production of surfactant, which
reduces the risk of Respiratory Distress Syndrome (RDS) in the neonate. This medication is
typically given in two doses, 24 hours apart, for maximum effectiveness.
5. Which clinical finding is most characteristic of Placenta Previa?
A. Severe abdominal pain with a board-like abdomen.
B. Sudden drop in blood pressure without visible bleeding.
C. Intermittent lower back pain with dark red spotting.
D. Painless, bright red vaginal bleeding in the third trimester.
Correct Answer: D
Explanation: Placenta previa occurs when the placenta covers the cervical os, leading to
painless, bright red bleeding as the cervix begins to dilate. Unlike abruptio placentae, there
