NUR 2633/NUR2633 Exam 4 V3 | Maternal Child
Health Nursing Q&A with Rationale | Rasmussen
University
1. A nurse is assessing a postpartum client 2 hours after delivery and finds the fundus is boggy
and displaced to the right. What is the priority nursing action?
A. Assist the client to the bathroom to void
B. Administer oxytocin as prescribed
C. Perform vigorous fundal massage
D. Notify the provider immediately
Correct Answer: A
Explanation: A fundus that is displaced to the right and boggy typically indicates 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 firm up. While fundal massage is
important for a boggy uterus, addressing the displacement caused by the bladder is the
priority in this specific scenario.
2. A nurse is caring for a client in labor who is receiving an oxytocin infusion. The nurse notes
late decelerations on the fetal heart rate monitor. Which action should the nurse take first?
A. Increase the oxytocin infusion rate
B. Place the client in a supine position
,C. Discontinue the oxytocin infusion
D. Administer oxygen via non-rebreather mask at 10 L/min
Correct Answer: C
Explanation: Late decelerations indicate uteroplacental insufficiency, which is a sign of
fetal distress. The first priority is to stop the oxytocin infusion to decrease uterine activity
and improve blood flow to the placenta. Following this, the nurse should reposition the
client, provide oxygen, and increase IV fluids as secondary interventions.
3. Which of the following clinical manifestations should a nurse expect to find in a child
diagnosed with intussusception?
A. Currant jelly-like stools
B. Projectile vomiting
C. Ribbon-like stools
D. Steatorrhea
Correct Answer: A
Explanation: Intussusception occurs when one portion of the bowel slides into the next,
often leading to intestinal obstruction and ischemia. This condition is characteristically
associated with stools that contain blood and mucus, giving them a ‘currant jelly’
appearance. Projectile vomiting is more indicative of pyloric stenosis, while ribbon-like
stools are associated with Hirschsprung’s disease.
, 4. A newborn has an APGAR score of 7 at 1 minute and 9 at 5 minutes. How should the nurse
interpret these findings?
A. The newborn requires immediate resuscitation
B. The newborn is experiencing severe respiratory distress
C. The newborn needs to be placed in an isolette for observation
D. The newborn is adjusting well to extrauterine life
Correct Answer: D
Explanation: APGAR scores between 7 and 10 are considered normal and indicate that the
newborn is making a good transition to life outside the womb. A score of 7 at 1 minute is
common as the infant adjusts, and an increase to 9 at 5 minutes shows improvement. No
emergency interventions are required for scores in this range beyond standard newborn
care.
5. A nurse is teaching a parent of a child with cystic fibrosis about nutrition. Which instruction
should be included?
A. Limit fat intake to less than 20% of total calories
B. Provide a low-protein diet to protect kidney function
C. Restict fluid intake to prevent pulmonary congestion
D. Administer pancreatic enzymes with all meals and snacks
Correct Answer: D
Health Nursing Q&A with Rationale | Rasmussen
University
1. A nurse is assessing a postpartum client 2 hours after delivery and finds the fundus is boggy
and displaced to the right. What is the priority nursing action?
A. Assist the client to the bathroom to void
B. Administer oxytocin as prescribed
C. Perform vigorous fundal massage
D. Notify the provider immediately
Correct Answer: A
Explanation: A fundus that is displaced to the right and boggy typically indicates 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 firm up. While fundal massage is
important for a boggy uterus, addressing the displacement caused by the bladder is the
priority in this specific scenario.
2. A nurse is caring for a client in labor who is receiving an oxytocin infusion. The nurse notes
late decelerations on the fetal heart rate monitor. Which action should the nurse take first?
A. Increase the oxytocin infusion rate
B. Place the client in a supine position
,C. Discontinue the oxytocin infusion
D. Administer oxygen via non-rebreather mask at 10 L/min
Correct Answer: C
Explanation: Late decelerations indicate uteroplacental insufficiency, which is a sign of
fetal distress. The first priority is to stop the oxytocin infusion to decrease uterine activity
and improve blood flow to the placenta. Following this, the nurse should reposition the
client, provide oxygen, and increase IV fluids as secondary interventions.
3. Which of the following clinical manifestations should a nurse expect to find in a child
diagnosed with intussusception?
A. Currant jelly-like stools
B. Projectile vomiting
C. Ribbon-like stools
D. Steatorrhea
Correct Answer: A
Explanation: Intussusception occurs when one portion of the bowel slides into the next,
often leading to intestinal obstruction and ischemia. This condition is characteristically
associated with stools that contain blood and mucus, giving them a ‘currant jelly’
appearance. Projectile vomiting is more indicative of pyloric stenosis, while ribbon-like
stools are associated with Hirschsprung’s disease.
, 4. A newborn has an APGAR score of 7 at 1 minute and 9 at 5 minutes. How should the nurse
interpret these findings?
A. The newborn requires immediate resuscitation
B. The newborn is experiencing severe respiratory distress
C. The newborn needs to be placed in an isolette for observation
D. The newborn is adjusting well to extrauterine life
Correct Answer: D
Explanation: APGAR scores between 7 and 10 are considered normal and indicate that the
newborn is making a good transition to life outside the womb. A score of 7 at 1 minute is
common as the infant adjusts, and an increase to 9 at 5 minutes shows improvement. No
emergency interventions are required for scores in this range beyond standard newborn
care.
5. A nurse is teaching a parent of a child with cystic fibrosis about nutrition. Which instruction
should be included?
A. Limit fat intake to less than 20% of total calories
B. Provide a low-protein diet to protect kidney function
C. Restict fluid intake to prevent pulmonary congestion
D. Administer pancreatic enzymes with all meals and snacks
Correct Answer: D
