NUR 2633/NUR2633 Final Exam V1 | Maternal
Child Health Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is caring for a client who is in labor and has a suspected placenta previa. Which of
the following actions should the nurse avoid?
A. Monitoring fetal heart rate via external monitor
B. Performing a vaginal examination to check dilation
C. Initiating intravenous access for fluids
D. Assessing the amount of vaginal bleeding
Correct Answer: B
Explanation: Performing a vaginal exam in a client with placenta previa can cause
catastrophic hemorrhage by puncturing the placenta. The nurse should notify the provider
and expect an ultrasound to confirm placental placement. Safety is the priority when
painless bright red bleeding is present in the third trimester.
2. A postpartum nurse is assessing a client 2 hours after delivery. The client’s fundus is soft
and deviated to the right. Which action should the nurse take first?
A. Administer oxytocin as ordered
B. Perform vigorous fundal massage
C. Assist the client to the bathroom to void
,D. Notify the healthcare provider immediately
Correct Answer: C
Explanation: A fundus that is deviated to the right and soft usually indicates a distended
bladder. A full bladder displaces the uterus and prevents it from contracting effectively,
which increases the risk of hemorrhage. After the client voids, the nurse should re-assess
the fundal position and consistency.
3. A nurse is assessing a newborn at 1 minute after birth and finds: HR 110, slow/irregular
respiratory effort, some flexion of extremities, grimace in response to suctioning, and a pink
body with blue extremities. What is the Apgar score?
A. 5
B. 8
C. 7
D. 6
Correct Answer: D
Explanation: The score is 6 based on the following: Heart rate over 100 (2), slow/irregular
respirations (1), some flexion (1), grimace (1), and acrocyanosis (1). Apgar scores below 7
at 5 minutes usually require further intervention or closer monitoring. This assessment
helps determine the transition of the newborn to extrauterine life.
, 4. A client at 34 weeks gestation is receiving Magnesium Sulfate for preeclampsia. Which
finding should the nurse report to the provider immediately?
A. Respirations of 10 breaths per minute
B. Urinary output of 40 mL per hour
C. Deep tendon reflexes of 2+
D. A feeling of warmth and flushing
Correct Answer: A
Explanation: Magnesium sulfate toxicity is characterized by a decrease in respiratory rate,
loss of deep tendon reflexes, and oliguria. A respiratory rate of 10 is dangerously low and
suggests the infusion should be stopped. Calcium gluconate is the standard antidote that
should be kept at the bedside during therapy.
5. A nurse is monitoring a fetal heart rate tracing and notes a pattern of variable
decelerations. What is the most appropriate nursing intervention?
A. Increase the rate of the IV infusion
B. Prepare for an emergency cesarean section
C. Administer oxygen via non-rebreather mask
D. Reposition the client to a side-lying position
Correct Answer: D
Child Health Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is caring for a client who is in labor and has a suspected placenta previa. Which of
the following actions should the nurse avoid?
A. Monitoring fetal heart rate via external monitor
B. Performing a vaginal examination to check dilation
C. Initiating intravenous access for fluids
D. Assessing the amount of vaginal bleeding
Correct Answer: B
Explanation: Performing a vaginal exam in a client with placenta previa can cause
catastrophic hemorrhage by puncturing the placenta. The nurse should notify the provider
and expect an ultrasound to confirm placental placement. Safety is the priority when
painless bright red bleeding is present in the third trimester.
2. A postpartum nurse is assessing a client 2 hours after delivery. The client’s fundus is soft
and deviated to the right. Which action should the nurse take first?
A. Administer oxytocin as ordered
B. Perform vigorous fundal massage
C. Assist the client to the bathroom to void
,D. Notify the healthcare provider immediately
Correct Answer: C
Explanation: A fundus that is deviated to the right and soft usually indicates a distended
bladder. A full bladder displaces the uterus and prevents it from contracting effectively,
which increases the risk of hemorrhage. After the client voids, the nurse should re-assess
the fundal position and consistency.
3. A nurse is assessing a newborn at 1 minute after birth and finds: HR 110, slow/irregular
respiratory effort, some flexion of extremities, grimace in response to suctioning, and a pink
body with blue extremities. What is the Apgar score?
A. 5
B. 8
C. 7
D. 6
Correct Answer: D
Explanation: The score is 6 based on the following: Heart rate over 100 (2), slow/irregular
respirations (1), some flexion (1), grimace (1), and acrocyanosis (1). Apgar scores below 7
at 5 minutes usually require further intervention or closer monitoring. This assessment
helps determine the transition of the newborn to extrauterine life.
, 4. A client at 34 weeks gestation is receiving Magnesium Sulfate for preeclampsia. Which
finding should the nurse report to the provider immediately?
A. Respirations of 10 breaths per minute
B. Urinary output of 40 mL per hour
C. Deep tendon reflexes of 2+
D. A feeling of warmth and flushing
Correct Answer: A
Explanation: Magnesium sulfate toxicity is characterized by a decrease in respiratory rate,
loss of deep tendon reflexes, and oliguria. A respiratory rate of 10 is dangerously low and
suggests the infusion should be stopped. Calcium gluconate is the standard antidote that
should be kept at the bedside during therapy.
5. A nurse is monitoring a fetal heart rate tracing and notes a pattern of variable
decelerations. What is the most appropriate nursing intervention?
A. Increase the rate of the IV infusion
B. Prepare for an emergency cesarean section
C. Administer oxygen via non-rebreather mask
D. Reposition the client to a side-lying position
Correct Answer: D
