NUR 2633/NUR2633 Exam 4 V2 | Maternal Child
Health Nursing Q&A with Rationale | Rasmussen
University
1. A nurse is caring for a postpartum client who is experiencing excessive vaginal bleeding and
a boggy uterus. Which of the following actions should the nurse take first?
A. Massage the uterine fundus.
B. Encourage the client to void.
C. Administer oxytocin IV infusion.
D. Notify the healthcare provider.
Correct Answer: A
Explanation: Fundal massage is the priority intervention for uterine atony to stimulate
uterine contraction and minimize blood loss. A boggy uterus indicates that the muscle
fibers are not contracting effectively to compress the intramyometrial blood vessels. After
the fundus is massaged and tone is assessed, other interventions such as emptying the
bladder or administering medications can be performed.
2. A nurse is monitoring a client who is receiving magnesium sulfate for preeclampsia. The
nurse should identify which of the following findings as an indication of toxicity?
A. Increased urine output.
B. Hyperreflexia (4+).
,C. Blood pressure 150/95 mmHg.
D. Respiratory rate of 10/min.
Correct Answer: D
Explanation: A respiratory rate below 12/min is a primary sign of magnesium sulfate
toxicity because it acts as a central nervous system depressant. The nurse must also
monitor for the loss of deep tendon reflexes and a decrease in urinary output. If toxicity is
suspected, the infusion must be stopped immediately and the calcium gluconate antidote
should be prepared.
3. A nurse is assessing a newborn whose mother used opioids during pregnancy. Which of the
following findings should the nurse expect to see in a neonate with Neonatal Abstinence
Syndrome (NAS)?
A. High-pitched, shrill cry and tremors.
B. Excessive sleepiness and lethargy.
C. Hypothermia and bradycardia.
D. Strong, rhythmic sucking reflex.
Correct Answer: A
Explanation: Neonatal Abstinence Syndrome presents with signs of CNS irritability,
including a high-pitched cry, tremors, and hyperreflexia. Infants also typically exhibit poor
feeding patterns, gastrointestinal upset, and sneezing. It is crucial to provide a low-
stimulation environment and frequent small feedings to support these neonates.
,4. A nurse is teaching a parent of a toddler who has laryngotracheobronchitis (croup). Which
of the following statements by the parent indicates an understanding of the teaching?
A. I will give my child honey to soothe the cough.
B. I will use a cool-mist humidifier in my child’s room.
C. I should expect my child to have a high fever.
D. I will restrict my child’s fluid intake.
Correct Answer: B
Explanation: Cool mist helps to moisten the airway and reduce the edema of the subglottic
area that causes the characteristic barking cough of croup. Parents should be taught to
monitor for signs of respiratory distress, such as stridor or retractions. Hydration is also
encouraged to help thin secretions, contrary to restricting fluids.
5. A nurse is caring for an infant who has intussusception. Which of the following clinical
findings is a classic sign of this condition?
A. Ribbon-like, foul-smelling stools.
B. Currant jelly-like stools.
C. Projectile vomiting after feeding.
D. Olive-shaped mass in the right upper quadrant.
Correct Answer: B
, Explanation: Intussusception occurs when one portion of the intestine telescopes into
another, leading to blood and mucus in the stool, described as ‘currant jelly.’ The child often
experiences sudden, acute abdominal pain and may draw their knees to their chest. While a
sausage-shaped mass might be palpable, the currant jelly stool is the hallmark diagnostic
indicator.
6. A nurse is caring for a 1-month-old infant who has pyloric stenosis. Which of the following
findings should the nurse expect?
A. Steatorrhea.
B. Projectile vomiting.
C. Chronic diarrhea.
D. Distended neck veins.
Correct Answer: B
Explanation: Pyloric stenosis is characterized by a thickening of the pyloric sphincter,
which obstructs gastric outlet and leads to non-bilious projectile vomiting. This vomiting
typically occurs shortly after feeding and can lead to severe dehydration and metabolic
alkalosis. An olive-shaped mass in the epigastrium is another key finding associated with
this condition.
7. A nurse is planning care for a child who has nephrotic syndrome. Which of the following
interventions should the nurse include?
A. Encourage a high-protein diet.
Health Nursing Q&A with Rationale | Rasmussen
University
1. A nurse is caring for a postpartum client who is experiencing excessive vaginal bleeding and
a boggy uterus. Which of the following actions should the nurse take first?
A. Massage the uterine fundus.
B. Encourage the client to void.
C. Administer oxytocin IV infusion.
D. Notify the healthcare provider.
Correct Answer: A
Explanation: Fundal massage is the priority intervention for uterine atony to stimulate
uterine contraction and minimize blood loss. A boggy uterus indicates that the muscle
fibers are not contracting effectively to compress the intramyometrial blood vessels. After
the fundus is massaged and tone is assessed, other interventions such as emptying the
bladder or administering medications can be performed.
2. A nurse is monitoring a client who is receiving magnesium sulfate for preeclampsia. The
nurse should identify which of the following findings as an indication of toxicity?
A. Increased urine output.
B. Hyperreflexia (4+).
,C. Blood pressure 150/95 mmHg.
D. Respiratory rate of 10/min.
Correct Answer: D
Explanation: A respiratory rate below 12/min is a primary sign of magnesium sulfate
toxicity because it acts as a central nervous system depressant. The nurse must also
monitor for the loss of deep tendon reflexes and a decrease in urinary output. If toxicity is
suspected, the infusion must be stopped immediately and the calcium gluconate antidote
should be prepared.
3. A nurse is assessing a newborn whose mother used opioids during pregnancy. Which of the
following findings should the nurse expect to see in a neonate with Neonatal Abstinence
Syndrome (NAS)?
A. High-pitched, shrill cry and tremors.
B. Excessive sleepiness and lethargy.
C. Hypothermia and bradycardia.
D. Strong, rhythmic sucking reflex.
Correct Answer: A
Explanation: Neonatal Abstinence Syndrome presents with signs of CNS irritability,
including a high-pitched cry, tremors, and hyperreflexia. Infants also typically exhibit poor
feeding patterns, gastrointestinal upset, and sneezing. It is crucial to provide a low-
stimulation environment and frequent small feedings to support these neonates.
,4. A nurse is teaching a parent of a toddler who has laryngotracheobronchitis (croup). Which
of the following statements by the parent indicates an understanding of the teaching?
A. I will give my child honey to soothe the cough.
B. I will use a cool-mist humidifier in my child’s room.
C. I should expect my child to have a high fever.
D. I will restrict my child’s fluid intake.
Correct Answer: B
Explanation: Cool mist helps to moisten the airway and reduce the edema of the subglottic
area that causes the characteristic barking cough of croup. Parents should be taught to
monitor for signs of respiratory distress, such as stridor or retractions. Hydration is also
encouraged to help thin secretions, contrary to restricting fluids.
5. A nurse is caring for an infant who has intussusception. Which of the following clinical
findings is a classic sign of this condition?
A. Ribbon-like, foul-smelling stools.
B. Currant jelly-like stools.
C. Projectile vomiting after feeding.
D. Olive-shaped mass in the right upper quadrant.
Correct Answer: B
, Explanation: Intussusception occurs when one portion of the intestine telescopes into
another, leading to blood and mucus in the stool, described as ‘currant jelly.’ The child often
experiences sudden, acute abdominal pain and may draw their knees to their chest. While a
sausage-shaped mass might be palpable, the currant jelly stool is the hallmark diagnostic
indicator.
6. A nurse is caring for a 1-month-old infant who has pyloric stenosis. Which of the following
findings should the nurse expect?
A. Steatorrhea.
B. Projectile vomiting.
C. Chronic diarrhea.
D. Distended neck veins.
Correct Answer: B
Explanation: Pyloric stenosis is characterized by a thickening of the pyloric sphincter,
which obstructs gastric outlet and leads to non-bilious projectile vomiting. This vomiting
typically occurs shortly after feeding and can lead to severe dehydration and metabolic
alkalosis. An olive-shaped mass in the epigastrium is another key finding associated with
this condition.
7. A nurse is planning care for a child who has nephrotic syndrome. Which of the following
interventions should the nurse include?
A. Encourage a high-protein diet.
