NUR 2633/NUR2633 Exam 2 V3 | Maternal Child
Health Nursing Q&A with Rationale | Rasmussen
University
1. A nurse is caring for a client who is at 34 weeks of gestation and is receiving magnesium
sulfate for preeclampsia. Which of the following findings should the nurse report to the
provider as a sign of toxicity?
A. Respiratory rate of 10/min
B. Urinary output of 40 mL/hr
C. Deep tendon reflexes of 2+
D. Fetal heart rate of 140/min
Correct Answer: A
Explanation: Magnesium sulfate toxicity causes central nervous system depression. A
respiratory rate below 12/min is a primary indicator of toxicity. The nurse must also
monitor for loss of deep tendon reflexes and decreased urinary output below 30 mL/hr.
2. Which of the following is a classic sign of placenta previa that differentiates it from
placental abruption?
A. Uterine tenderness and rigidity
B. Painless, bright red vaginal bleeding
C. Severe abdominal pain
,D. Board-like abdomen
Correct Answer: B
Explanation: Placenta previa is characterized by painless, bright red bleeding in the
second or third trimester. In contrast, placental abruption typically presents with dark red
bleeding, severe pain, and uterine tenderness. Recognizing this distinction is vital for
immediate nursing intervention.
3. A nurse is assessing a client in labor and observes variable decelerations on the fetal heart
rate monitor. Which of the following is the priority nursing action?
A. Change the client’s position to side-lying
B. Increase the rate of IV fluids
C. Administer oxygen via non-rebreather mask
D. Prepare for an immediate cesarean birth
Correct Answer: A
Explanation: Variable decelerations are caused by umbilical cord compression. Changing
the mother’s position is the first intervention to relieve pressure on the cord. If this does
not resolve the decelerations, then oxygen and amnioinfusion may be considered.
4. A client is 2 hours postpartum and the nurse finds the fundus to be boggy and displaced to
the right. Which of the following actions should the nurse take first?
A. Assist the client to the bathroom to void
, B. Perform fundal massage until firm
C. Administer oxytocin 20 units IM
D. Notify the provider immediately
Correct Answer: A
Explanation: A displaced fundus to the right usually indicates a full bladder, which
prevents the uterus from contracting effectively. Assisting the client to void is the priority
to allow the uterus to return to midline and contract. If it remains boggy after voiding, then
fundal massage should be performed.
5. A nurse is providing discharge teaching to a mother of a newborn. Which of the following
statements by the mother indicates an understanding of SIDS prevention?
A. I will place my baby on their back to sleep.
B. I will use soft bumper pads in the crib.
C. I will place my baby on their side to sleep.
D. I will keep the room temperature very warm.
Correct Answer: A
Explanation: The ‘Back to Sleep’ campaign is the most significant factor in reducing SIDS.
Infants should sleep on a firm surface in a supine position without blankets, pillows, or
toys. Side-lying is no longer recommended due to the risk of the infant rolling onto their
stomach.
Health Nursing Q&A with Rationale | Rasmussen
University
1. A nurse is caring for a client who is at 34 weeks of gestation and is receiving magnesium
sulfate for preeclampsia. Which of the following findings should the nurse report to the
provider as a sign of toxicity?
A. Respiratory rate of 10/min
B. Urinary output of 40 mL/hr
C. Deep tendon reflexes of 2+
D. Fetal heart rate of 140/min
Correct Answer: A
Explanation: Magnesium sulfate toxicity causes central nervous system depression. A
respiratory rate below 12/min is a primary indicator of toxicity. The nurse must also
monitor for loss of deep tendon reflexes and decreased urinary output below 30 mL/hr.
2. Which of the following is a classic sign of placenta previa that differentiates it from
placental abruption?
A. Uterine tenderness and rigidity
B. Painless, bright red vaginal bleeding
C. Severe abdominal pain
,D. Board-like abdomen
Correct Answer: B
Explanation: Placenta previa is characterized by painless, bright red bleeding in the
second or third trimester. In contrast, placental abruption typically presents with dark red
bleeding, severe pain, and uterine tenderness. Recognizing this distinction is vital for
immediate nursing intervention.
3. A nurse is assessing a client in labor and observes variable decelerations on the fetal heart
rate monitor. Which of the following is the priority nursing action?
A. Change the client’s position to side-lying
B. Increase the rate of IV fluids
C. Administer oxygen via non-rebreather mask
D. Prepare for an immediate cesarean birth
Correct Answer: A
Explanation: Variable decelerations are caused by umbilical cord compression. Changing
the mother’s position is the first intervention to relieve pressure on the cord. If this does
not resolve the decelerations, then oxygen and amnioinfusion may be considered.
4. A client is 2 hours postpartum and the nurse finds the fundus to be boggy and displaced to
the right. Which of the following actions should the nurse take first?
A. Assist the client to the bathroom to void
, B. Perform fundal massage until firm
C. Administer oxytocin 20 units IM
D. Notify the provider immediately
Correct Answer: A
Explanation: A displaced fundus to the right usually indicates a full bladder, which
prevents the uterus from contracting effectively. Assisting the client to void is the priority
to allow the uterus to return to midline and contract. If it remains boggy after voiding, then
fundal massage should be performed.
5. A nurse is providing discharge teaching to a mother of a newborn. Which of the following
statements by the mother indicates an understanding of SIDS prevention?
A. I will place my baby on their back to sleep.
B. I will use soft bumper pads in the crib.
C. I will place my baby on their side to sleep.
D. I will keep the room temperature very warm.
Correct Answer: A
Explanation: The ‘Back to Sleep’ campaign is the most significant factor in reducing SIDS.
Infants should sleep on a firm surface in a supine position without blankets, pillows, or
toys. Side-lying is no longer recommended due to the risk of the infant rolling onto their
stomach.
