NUR 2633/NUR2633 Exam 2 V2 | 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 should the nurse prioritize and report to the
provider immediately?
A. Deep tendon reflexes of 2+
B. Urinary output of 40 mL/hr
C. Respiratory rate of 10/min
D. Fetal heart rate of 130/min
Correct Answer: C
Explanation: Magnesium sulfate is a central nervous system depressant used to prevent
seizures in preeclamptic patients. A respiratory rate below 12/min is a primary indicator of
magnesium toxicity and requires immediate intervention. The nurse should also assess for
loss of deep tendon reflexes and a significant decrease in urinary output to ensure patient
safety.
2. Which of the following interventions should a nurse perform first when observing variable
decelerations on a fetal heart rate monitor?
A. Increase the rate of IV fluids
B. Change the client’s position
,C. Administer oxygen via nonrebreather mask
D. Perform a vaginal exam to check for cord prolapse
Correct Answer: B
Explanation: Variable decelerations are typically caused by umbilical cord compression
during labor. Changing the maternal position is the first action to relieve the pressure on
the cord and improve fetal oxygenation. If the decelerations persist, further interventions
like oxygen administration or amnioinfusion may be considered.
3. A nurse is assessing a client who is 2 hours postpartum and notes the fundus is boggy and
displaced to the right. What is the appropriate initial nursing action?
A. Administer oxytocin as prescribed
B. Perform fundal massage until firm
C. Assist the client to the bathroom to void
D. Notify the provider of a potential hemorrhage
Correct Answer: C
Explanation: A displaced fundus is often the result of a full bladder, which prevents the
uterus from contracting effectively. Assisting the client to void will allow the uterus to
return to the midline and contract, reducing the risk of hemorrhage. After voiding, the
nurse should re-evaluate the fundal position and firmness.
, 4. A client at 34 weeks of gestation presents with sudden-onset, dark red vaginal bleeding
and a board-like, tender abdomen. Which condition should the nurse suspect?
A. Placenta previa
B. Ectopic pregnancy
C. Abruptio placentae
D. Preterm labor
Correct Answer: C
Explanation: Abruptio placentae is characterized by the premature separation of the
placenta, causing dark red bleeding and significant abdominal pain/rigidity. In contrast,
placenta previa typically presents with painless, bright red bleeding. This condition is a
medical emergency that requires rapid assessment and possible delivery to ensure
maternal and fetal survival.
5. When administering the Hepatitis B vaccine to a newborn, which of the following is the
correct site for injection?
A. Dorsogluteal muscle
B. Vastus lateralis muscle
C. Deltoid muscle
D. Ventrogluteal muscle
Correct Answer: B
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 should the nurse prioritize and report to the
provider immediately?
A. Deep tendon reflexes of 2+
B. Urinary output of 40 mL/hr
C. Respiratory rate of 10/min
D. Fetal heart rate of 130/min
Correct Answer: C
Explanation: Magnesium sulfate is a central nervous system depressant used to prevent
seizures in preeclamptic patients. A respiratory rate below 12/min is a primary indicator of
magnesium toxicity and requires immediate intervention. The nurse should also assess for
loss of deep tendon reflexes and a significant decrease in urinary output to ensure patient
safety.
2. Which of the following interventions should a nurse perform first when observing variable
decelerations on a fetal heart rate monitor?
A. Increase the rate of IV fluids
B. Change the client’s position
,C. Administer oxygen via nonrebreather mask
D. Perform a vaginal exam to check for cord prolapse
Correct Answer: B
Explanation: Variable decelerations are typically caused by umbilical cord compression
during labor. Changing the maternal position is the first action to relieve the pressure on
the cord and improve fetal oxygenation. If the decelerations persist, further interventions
like oxygen administration or amnioinfusion may be considered.
3. A nurse is assessing a client who is 2 hours postpartum and notes the fundus is boggy and
displaced to the right. What is the appropriate initial nursing action?
A. Administer oxytocin as prescribed
B. Perform fundal massage until firm
C. Assist the client to the bathroom to void
D. Notify the provider of a potential hemorrhage
Correct Answer: C
Explanation: A displaced fundus is often the result of a full bladder, which prevents the
uterus from contracting effectively. Assisting the client to void will allow the uterus to
return to the midline and contract, reducing the risk of hemorrhage. After voiding, the
nurse should re-evaluate the fundal position and firmness.
, 4. A client at 34 weeks of gestation presents with sudden-onset, dark red vaginal bleeding
and a board-like, tender abdomen. Which condition should the nurse suspect?
A. Placenta previa
B. Ectopic pregnancy
C. Abruptio placentae
D. Preterm labor
Correct Answer: C
Explanation: Abruptio placentae is characterized by the premature separation of the
placenta, causing dark red bleeding and significant abdominal pain/rigidity. In contrast,
placenta previa typically presents with painless, bright red bleeding. This condition is a
medical emergency that requires rapid assessment and possible delivery to ensure
maternal and fetal survival.
5. When administering the Hepatitis B vaccine to a newborn, which of the following is the
correct site for injection?
A. Dorsogluteal muscle
B. Vastus lateralis muscle
C. Deltoid muscle
D. Ventrogluteal muscle
Correct Answer: B
