NUR2513 MATERNAL-CHILD NURSING
FINAL PREP QUESTIONS AND
ANSWERS
1. A client at 34 weeks gestation is receiving magnesium sulfate for preeclampsia. Which
assessment finding should lead the nurse to suspect magnesium toxicity?
A. Hyperreflexic patellar reflexes
B. Serum magnesium level of 6 mEq/L
C. Respiratory rate of 10 breaths per minute
D. Urinary output of 40 mL per hour
Answer: C
Conceptual Explanation: Magnesium toxicity is characterized by respiratory depression
(less than 12/min), loss of deep tendon reflexes, and decreased urinary output. A
respiratory rate of 10 is a critical indicator for immediate intervention.
2. Which fetal heart rate pattern should the nurse prioritize as requiring immediate
intervention during labor?
A. Early decelerations with head compression
,B. Late decelerations after the peak of a contraction
C. Accelerations with fetal movement
D. Variable decelerations with cord compression
Answer: B
Conceptual Explanation: Late decelerations are caused by uteroplacental insufficiency
and are considered non-reassuring, requiring immediate positioning, oxygen, and
notification of the provider.
3. An infant with Tetralogy of Fallot begins to cry and becomes cyanotic with a significant
increase in respiratory rate. What is the nurse’s priority action?
A. Administer high-flow oxygen via mask
B. Prepare for immediate intubation
C. Place the infant in the knee-chest position
D. Obtain a stat arterial blood gas
Answer: C
Conceptual Explanation: The knee-chest position increases systemic vascular resistance,
which helps reduce the right-to-left shunt in a ‘Tet spell,’ improving oxygenation.
4. A 4-year-old child is brought to the emergency department with a high fever, drooling, and
a muffled voice. The child is sitting in a ‘tripod’ position. What action is contraindicated?
A. Applying cool mist oxygen
, B. Obtaining a lateral neck X-ray
C. Assessing the throat with a tongue depressor
D. Inserting an intravenous line immediately
Answer: C
Conceptual Explanation: These are classic signs of epiglottitis. Using a tongue depressor
or any invasive throat exam can trigger laryngospasm and complete airway obstruction.
5. During a postpartum assessment 2 hours after delivery, the nurse notes the fundus is
boggy and displaced to the right of the midline. What is the nurse’s next action?
A. Massage the fundus until firm
B. Ask the client to empty her bladder
C. Increase the IV oxytocin rate
D. Notify the provider of a potential hemorrhage
Answer: B
Conceptual Explanation: A fundus displaced to the right and boggy usually indicates a
distended bladder, which prevents the uterus from contracting. Emptying the bladder is
the first step to allow the uterus to return to midline and firm up.
6. Which clinical manifestation is most characteristic of placenta previa?
A. Rigid, board-like abdomen
B. Painless, bright red vaginal bleeding
FINAL PREP QUESTIONS AND
ANSWERS
1. A client at 34 weeks gestation is receiving magnesium sulfate for preeclampsia. Which
assessment finding should lead the nurse to suspect magnesium toxicity?
A. Hyperreflexic patellar reflexes
B. Serum magnesium level of 6 mEq/L
C. Respiratory rate of 10 breaths per minute
D. Urinary output of 40 mL per hour
Answer: C
Conceptual Explanation: Magnesium toxicity is characterized by respiratory depression
(less than 12/min), loss of deep tendon reflexes, and decreased urinary output. A
respiratory rate of 10 is a critical indicator for immediate intervention.
2. Which fetal heart rate pattern should the nurse prioritize as requiring immediate
intervention during labor?
A. Early decelerations with head compression
,B. Late decelerations after the peak of a contraction
C. Accelerations with fetal movement
D. Variable decelerations with cord compression
Answer: B
Conceptual Explanation: Late decelerations are caused by uteroplacental insufficiency
and are considered non-reassuring, requiring immediate positioning, oxygen, and
notification of the provider.
3. An infant with Tetralogy of Fallot begins to cry and becomes cyanotic with a significant
increase in respiratory rate. What is the nurse’s priority action?
A. Administer high-flow oxygen via mask
B. Prepare for immediate intubation
C. Place the infant in the knee-chest position
D. Obtain a stat arterial blood gas
Answer: C
Conceptual Explanation: The knee-chest position increases systemic vascular resistance,
which helps reduce the right-to-left shunt in a ‘Tet spell,’ improving oxygenation.
4. A 4-year-old child is brought to the emergency department with a high fever, drooling, and
a muffled voice. The child is sitting in a ‘tripod’ position. What action is contraindicated?
A. Applying cool mist oxygen
, B. Obtaining a lateral neck X-ray
C. Assessing the throat with a tongue depressor
D. Inserting an intravenous line immediately
Answer: C
Conceptual Explanation: These are classic signs of epiglottitis. Using a tongue depressor
or any invasive throat exam can trigger laryngospasm and complete airway obstruction.
5. During a postpartum assessment 2 hours after delivery, the nurse notes the fundus is
boggy and displaced to the right of the midline. What is the nurse’s next action?
A. Massage the fundus until firm
B. Ask the client to empty her bladder
C. Increase the IV oxytocin rate
D. Notify the provider of a potential hemorrhage
Answer: B
Conceptual Explanation: A fundus displaced to the right and boggy usually indicates a
distended bladder, which prevents the uterus from contracting. Emptying the bladder is
the first step to allow the uterus to return to midline and firm up.
6. Which clinical manifestation is most characteristic of placenta previa?
A. Rigid, board-like abdomen
B. Painless, bright red vaginal bleeding
