NUR 2633/NUR2633 Exam 2 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 the treatment of
preeclampsia. Which of the following findings is the priority for the nurse to report to the
provider?
A. Respiratory rate of 10/min
B. Urinary output of 40 mL/hr
C. Generalized pruritus
D. Deep tendon reflexes of 2+
Correct Answer: A
Explanation: Magnesium sulfate toxicity is a critical complication that can lead to
respiratory depression and cardiac arrest. A respiratory rate below 12/min is a primary
indicator of magnesium toxicity and requires immediate cessation of the infusion. The
nurse should also prepare to administer calcium gluconate as the antagonist.
2. A nurse is assessing a client who is at 32 weeks of gestation and reports painless, bright red
vaginal bleeding. Which of the following conditions should the nurse suspect?
A. Abruptio placentae
B. Placenta previa
,C. Preterm labor
D. Hydatidiform mole
Correct Answer: B
Explanation: Placenta previa is characterized by the placenta covering the cervical os,
resulting in painless, bright red bleeding during the third trimester. This differs from
placental abruption, which typically involves painful, dark red bleeding and uterine rigidity.
It is vital for the nurse to avoid performing a vaginal exam on this client to prevent further
hemorrhage.
3. A nurse is calculating a client’s GTPAL. The client is currently pregnant, has a child born at
39 weeks, twins born at 34 weeks, and had a miscarriage at 10 weeks. What is the correct
GTPAL?
A. G4, T2, P1, A1, L3
B. G3, T1, P1, A1, L2
C. G4, T1, P1, A1, L3
D. G4, T1, P2, A1, L3
Correct Answer: C
Explanation: The client is currently pregnant (G4), has one term birth at 39 weeks (T1),
and one preterm birth of twins (P1, as twins count as one event). The miscarriage at 10
weeks counts as an abortion (A1), and she has three living children (L3). Accurate GTPAL
scoring is essential for assessing obstetric history and identifying potential risks.
,4. 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. Increase the IV fluid rate
B. Assist the client into a lateral position
C. Administer oxygen via face mask
D. Notify the provider
Correct Answer: B
Explanation: Late decelerations are indicative of uteroplacental insufficiency and require
immediate nursing intervention to improve oxygenation. The first step is to reposition the
client to a side-lying position to displace the uterus from the vena cava and improve blood
flow. Following repositioning, the nurse should increase fluids, apply oxygen, and notify the
provider.
5. A nurse is caring for a client who is in the transition phase of labor. Which of the following
characteristics should the nurse expect?
A. Cervical dilation of 1 to 3 cm
B. Client is talkative and eager
C. Contractions every 10 to 15 minutes
D. Cervical dilation of 8 to 10 cm
Correct Answer: D
, Explanation: The transition phase is the final part of the first stage of labor, characterized
by cervical dilation of 8 to 10 cm. During this phase, contractions are intense, frequent, and
long-lasting, often leading the client to feel a loss of control or urge to push. This phase is
typically the shortest but most difficult part of labor for the mother.
6. A nurse is assessing a newborn 1 hour after birth. Which of the following findings should
the nurse report to the provider?
A. Acrocyanosis
B. Nasal flaring
C. Generalized petechiae
D. Respiratory rate of 50/min
Correct Answer: B
Explanation: Nasal flaring is a significant sign of respiratory distress in a newborn and
requires immediate evaluation. While acrocyanosis is common in the first 24 hours, nasal
flaring, grunting, and retractions indicate the neonate is struggling to breathe. The nurse
must prioritize airway and breathing assessments to ensure neonatal stability.
7. A nurse is caring for a client who is 4 hours postpartum and has a saturated perineal pad in
15 minutes. What is the nurse’s first action?
A. Assess the blood pressure
B. Administer oxytocin IV
C. Notify the provider
Health Nursing Q&A with Rationale | Rasmussen
University
1. A nurse is caring for a client who is receiving magnesium sulfate for the treatment of
preeclampsia. Which of the following findings is the priority for the nurse to report to the
provider?
A. Respiratory rate of 10/min
B. Urinary output of 40 mL/hr
C. Generalized pruritus
D. Deep tendon reflexes of 2+
Correct Answer: A
Explanation: Magnesium sulfate toxicity is a critical complication that can lead to
respiratory depression and cardiac arrest. A respiratory rate below 12/min is a primary
indicator of magnesium toxicity and requires immediate cessation of the infusion. The
nurse should also prepare to administer calcium gluconate as the antagonist.
2. A nurse is assessing a client who is at 32 weeks of gestation and reports painless, bright red
vaginal bleeding. Which of the following conditions should the nurse suspect?
A. Abruptio placentae
B. Placenta previa
,C. Preterm labor
D. Hydatidiform mole
Correct Answer: B
Explanation: Placenta previa is characterized by the placenta covering the cervical os,
resulting in painless, bright red bleeding during the third trimester. This differs from
placental abruption, which typically involves painful, dark red bleeding and uterine rigidity.
It is vital for the nurse to avoid performing a vaginal exam on this client to prevent further
hemorrhage.
3. A nurse is calculating a client’s GTPAL. The client is currently pregnant, has a child born at
39 weeks, twins born at 34 weeks, and had a miscarriage at 10 weeks. What is the correct
GTPAL?
A. G4, T2, P1, A1, L3
B. G3, T1, P1, A1, L2
C. G4, T1, P1, A1, L3
D. G4, T1, P2, A1, L3
Correct Answer: C
Explanation: The client is currently pregnant (G4), has one term birth at 39 weeks (T1),
and one preterm birth of twins (P1, as twins count as one event). The miscarriage at 10
weeks counts as an abortion (A1), and she has three living children (L3). Accurate GTPAL
scoring is essential for assessing obstetric history and identifying potential risks.
,4. 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. Increase the IV fluid rate
B. Assist the client into a lateral position
C. Administer oxygen via face mask
D. Notify the provider
Correct Answer: B
Explanation: Late decelerations are indicative of uteroplacental insufficiency and require
immediate nursing intervention to improve oxygenation. The first step is to reposition the
client to a side-lying position to displace the uterus from the vena cava and improve blood
flow. Following repositioning, the nurse should increase fluids, apply oxygen, and notify the
provider.
5. A nurse is caring for a client who is in the transition phase of labor. Which of the following
characteristics should the nurse expect?
A. Cervical dilation of 1 to 3 cm
B. Client is talkative and eager
C. Contractions every 10 to 15 minutes
D. Cervical dilation of 8 to 10 cm
Correct Answer: D
, Explanation: The transition phase is the final part of the first stage of labor, characterized
by cervical dilation of 8 to 10 cm. During this phase, contractions are intense, frequent, and
long-lasting, often leading the client to feel a loss of control or urge to push. This phase is
typically the shortest but most difficult part of labor for the mother.
6. A nurse is assessing a newborn 1 hour after birth. Which of the following findings should
the nurse report to the provider?
A. Acrocyanosis
B. Nasal flaring
C. Generalized petechiae
D. Respiratory rate of 50/min
Correct Answer: B
Explanation: Nasal flaring is a significant sign of respiratory distress in a newborn and
requires immediate evaluation. While acrocyanosis is common in the first 24 hours, nasal
flaring, grunting, and retractions indicate the neonate is struggling to breathe. The nurse
must prioritize airway and breathing assessments to ensure neonatal stability.
7. A nurse is caring for a client who is 4 hours postpartum and has a saturated perineal pad in
15 minutes. What is the nurse’s first action?
A. Assess the blood pressure
B. Administer oxytocin IV
C. Notify the provider
