NUR 2633/NUR2633 Final Exam V2 | Maternal
Child Health Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is caring for a client who is at 36 weeks of gestation and has a prescription for a
nonstress test. Which of the following instructions should the nurse provide to the client?
A. You will need to drink a glucose solution before the test.
B. You will need to remain NPO for 4 hours prior to the procedure.
C. You will press a button when you feel the baby move.
D. This test will determine if your baby’s lungs are mature.
Correct Answer: C
Explanation: A nonstress test (NST) is a non-invasive procedure used to evaluate fetal
well-being by monitoring the fetal heart rate response to fetal movement. The client is
instructed to press a handheld button whenever she feels the fetus move, which allows the
nurse to correlate the movement with the heart rate pattern. A reactive NST is defined by
the presence of at least two accelerations within a 20-minute period.
2. A nurse is assessing a client who is in the first stage of labor. The nurse notes early
decelerations on the fetal heart rate monitor. Which of the following actions should the nurse
take?
A. Document the finding and continue to monitor.
B. Place the client in a Trendelenburg position.
,C. Prepare for an emergency cesarean birth.
D. Administer oxygen at 10 L/min via nonrebreather mask.
Correct Answer: A
Explanation: Early decelerations are caused by fetal head compression during
contractions and are considered a benign finding. They typically mirror the contraction and
do not indicate fetal distress or hypoxia. Therefore, the nurse should document the finding
as a normal part of labor progress and continue routine monitoring.
3. A nurse is caring for a client who is 2 hours postpartum and has a boggy uterus with heavy
lochia. Which of the following medications should the nurse expect to administer first?
A. Oxytocin
B. Magnesium sulfate
C. Terbutaline
D. Betamethasone
Correct Answer: A
Explanation: Oxytocin is the first-line medication used to promote uterine contractions
and prevent postpartum hemorrhage in the presence of uterine atony (a boggy uterus).
Terbutaline and magnesium sulfate are used to stop contractions in preterm labor, not to
start them. Betamethasone is administered to the mother to promote fetal lung maturity in
cases of anticipated preterm delivery.
,4. A nurse is providing teaching to a client who is at 12 weeks of gestation and has a new
diagnosis of hyperemesis gravidarum. Which of the following statements by the client
indicates an understanding of the teaching?
A. I will eat dry crackers before I get out of bed in the morning.
B. I will drink fluids with my meals to stay hydrated.
C. I will eat three large meals a day to keep my energy up.
D. I will increase my intake of high-fat foods.
Correct Answer: A
Explanation: Eating dry crackers or toast before rising can help settle the stomach and
manage the nausea associated with hyperemesis gravidarum. Clients should be encouraged
to eat small, frequent meals throughout the day rather than three large ones. It is also
recommended to consume fluids between meals rather than with meals to prevent over-
distension of the stomach.
5. A nurse is assessing a newborn 1 hour after birth. Which of the following findings should
the nurse report to the provider?
A. Generalized petechiae
B. Respiratory rate of 48/min
C. Heart rate of 140/min
D. Acrocyanosis
, Correct Answer: A
Explanation: Generalized petechiae can indicate a systemic infection or a clotting disorder
and should be reported immediately to the provider. A heart rate of 140/min and a
respiratory rate of 48/min are within the normal reference range for a newborn.
Acrocyanosis, which is a bluish discoloration of the hands and feet, is a common and
normal finding in the first 24 to 48 hours of life.
6. A nurse is providing discharge teaching to the parents of a child who has cystic fibrosis.
Which of the following dietary recommendations should the nurse include?
A. Restrict calorie intake to prevent obesity.
B. Increase the intake of high-protein, high-calorie foods.
C. Administer pancreatic enzymes 2 hours after meals.
D. Limit the intake of sodium and fat.
Correct Answer: B
Explanation: Children with cystic fibrosis require a high-protein, high-calorie diet to
support growth and compensate for malabsorption issues. Pancreatic enzymes must be
administered with every meal and snack to ensure proper digestion and nutrient
absorption. Unlike many other conditions, sodium intake is often encouraged because these
children lose excessive salt through their sweat.
Child Health Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is caring for a client who is at 36 weeks of gestation and has a prescription for a
nonstress test. Which of the following instructions should the nurse provide to the client?
A. You will need to drink a glucose solution before the test.
B. You will need to remain NPO for 4 hours prior to the procedure.
C. You will press a button when you feel the baby move.
D. This test will determine if your baby’s lungs are mature.
Correct Answer: C
Explanation: A nonstress test (NST) is a non-invasive procedure used to evaluate fetal
well-being by monitoring the fetal heart rate response to fetal movement. The client is
instructed to press a handheld button whenever she feels the fetus move, which allows the
nurse to correlate the movement with the heart rate pattern. A reactive NST is defined by
the presence of at least two accelerations within a 20-minute period.
2. A nurse is assessing a client who is in the first stage of labor. The nurse notes early
decelerations on the fetal heart rate monitor. Which of the following actions should the nurse
take?
A. Document the finding and continue to monitor.
B. Place the client in a Trendelenburg position.
,C. Prepare for an emergency cesarean birth.
D. Administer oxygen at 10 L/min via nonrebreather mask.
Correct Answer: A
Explanation: Early decelerations are caused by fetal head compression during
contractions and are considered a benign finding. They typically mirror the contraction and
do not indicate fetal distress or hypoxia. Therefore, the nurse should document the finding
as a normal part of labor progress and continue routine monitoring.
3. A nurse is caring for a client who is 2 hours postpartum and has a boggy uterus with heavy
lochia. Which of the following medications should the nurse expect to administer first?
A. Oxytocin
B. Magnesium sulfate
C. Terbutaline
D. Betamethasone
Correct Answer: A
Explanation: Oxytocin is the first-line medication used to promote uterine contractions
and prevent postpartum hemorrhage in the presence of uterine atony (a boggy uterus).
Terbutaline and magnesium sulfate are used to stop contractions in preterm labor, not to
start them. Betamethasone is administered to the mother to promote fetal lung maturity in
cases of anticipated preterm delivery.
,4. A nurse is providing teaching to a client who is at 12 weeks of gestation and has a new
diagnosis of hyperemesis gravidarum. Which of the following statements by the client
indicates an understanding of the teaching?
A. I will eat dry crackers before I get out of bed in the morning.
B. I will drink fluids with my meals to stay hydrated.
C. I will eat three large meals a day to keep my energy up.
D. I will increase my intake of high-fat foods.
Correct Answer: A
Explanation: Eating dry crackers or toast before rising can help settle the stomach and
manage the nausea associated with hyperemesis gravidarum. Clients should be encouraged
to eat small, frequent meals throughout the day rather than three large ones. It is also
recommended to consume fluids between meals rather than with meals to prevent over-
distension of the stomach.
5. A nurse is assessing a newborn 1 hour after birth. Which of the following findings should
the nurse report to the provider?
A. Generalized petechiae
B. Respiratory rate of 48/min
C. Heart rate of 140/min
D. Acrocyanosis
, Correct Answer: A
Explanation: Generalized petechiae can indicate a systemic infection or a clotting disorder
and should be reported immediately to the provider. A heart rate of 140/min and a
respiratory rate of 48/min are within the normal reference range for a newborn.
Acrocyanosis, which is a bluish discoloration of the hands and feet, is a common and
normal finding in the first 24 to 48 hours of life.
6. A nurse is providing discharge teaching to the parents of a child who has cystic fibrosis.
Which of the following dietary recommendations should the nurse include?
A. Restrict calorie intake to prevent obesity.
B. Increase the intake of high-protein, high-calorie foods.
C. Administer pancreatic enzymes 2 hours after meals.
D. Limit the intake of sodium and fat.
Correct Answer: B
Explanation: Children with cystic fibrosis require a high-protein, high-calorie diet to
support growth and compensate for malabsorption issues. Pancreatic enzymes must be
administered with every meal and snack to ensure proper digestion and nutrient
absorption. Unlike many other conditions, sodium intake is often encouraged because these
children lose excessive salt through their sweat.
