TEST BANK RATIONALE: NUR2513
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MATERNAL-CHILD NURSING FINAL EXAM = = = =
(2026/2027 UPDATED) = =
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Overview Rationale =
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Section 1: Antepartum (Prenatal Care)
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1. A primigravida at 32 weeks gestation presents for a routine
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prenatal visit. Fundal height measurement is 28 cm. What is
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the PRIORITY nursing action?
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• A) Document the findings as normal
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• B) Notify the healthcare provider of the fundal height
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discrepancy and prepare for further evaluation
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• C) Instruct the patient to increase caloric intake
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• D) Schedule the next visit in 4 weeks
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Answer: B = =
,Rationale: A fundal height that is more than 3 cm off from the
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gestational age, or one that shows inadequate interval growth,
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may indicate intrauterine growth restriction (IUGR),
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oligohydramnios, or other complications . Between 18- = = = = = =
32 weeks, fundal height in centimeters should correspond with
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weeks of gestation (within 2-
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3 cm). At 20 weeks, the fundus is typically at the level of the
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umbilicus, measuring approximately 20 cm. Significant
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discrepancies require further evaluation such as ultrasound .
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Cognitive Level: Application | Exam Domain: Antepartum
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2. A client at 8 weeks gestation tells the nurse, "I'm not sure I
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want to continue with this pregnancy." What is the nurse's
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BEST response? = =
• A) "You should discuss this with the baby's father."
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• B) "Tell me more about how you are feeling."
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• C) "Don't worry; most women feel this way at first."
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• D) "You need to make a decision soon before it's too late."
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Answer: B = =
,Rationale: This open- = =
ended statement allows the client to express her feelings and
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concerns without judgment. It demonstrates therapeutic
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communication and provides an opportunity for the nurse to assess
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for risk factors such as depression, lack of support, or ambivalence .
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The nurse should never dismiss feelings or rush the decision-
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making process. = =
Cognitive Level: Application | Exam
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Domain: Antepartum/Therapeutic Communication
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3. A nurse is teaching a primigravida about expected body
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changes during the first trimester. Which findings should the
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nurse include? (Select All That Apply)
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• A) Urinary frequency
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• B) Quickening
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• C) Breast tenderness
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• D) Nausea and vomiting
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• E) Braxton Hicks contractions
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Answer: A, C, D = = = =
, Rationale: First trimester changes (weeks 1-
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12) include urinary frequency (due to hormonal changes and
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uterine pressure on bladder), breast tenderness (from increased
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estrogen and progesterone), and nausea/vomiting (morning
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sickness) . Quickening (first fetal movements) is typically felt at 18-
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20 weeks (second trimester) . Braxton Hicks contractions usually
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begin in the second or third trimester .
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Cognitive Level: Comprehension | Exam Domain: Antepartum
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4. At 36 weeks gestation, a client asks the nurse why she is havi
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ng difficulty breathing. What is the MOST accurate explanatio
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n? =
• A) "The baby has dropped into the pelvis, making it easier to
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breathe." =
• B) "Your uterus is pushing up against your diaphragm."
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• C) "You may have developed asthma during pregnancy."
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• D) "This is a sign of preeclampsia."
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Answer: B = =
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MATERNAL-CHILD NURSING FINAL EXAM = = = =
(2026/2027 UPDATED) = =
=
Overview Rationale =
=
Section 1: Antepartum (Prenatal Care)
= = = = =
1. A primigravida at 32 weeks gestation presents for a routine
= = = = = = = = = =
prenatal visit. Fundal height measurement is 28 cm. What is
= = = = = = = = = =
the PRIORITY nursing action?
= = = =
• A) Document the findings as normal
= = = = = =
• B) Notify the healthcare provider of the fundal height
= = = = = = = =
discrepancy and prepare for further evaluation
= = = = = = =
• C) Instruct the patient to increase caloric intake
= = = = = = = =
• D) Schedule the next visit in 4 weeks
= = = = = = = =
Answer: B = =
,Rationale: A fundal height that is more than 3 cm off from the
= = = = = = = = = = = = =
gestational age, or one that shows inadequate interval growth,
= = = = = = = = =
may indicate intrauterine growth restriction (IUGR),
= = = = = =
oligohydramnios, or other complications . Between 18- = = = = = =
32 weeks, fundal height in centimeters should correspond with
= = = = = = = = =
weeks of gestation (within 2-
= = = =
3 cm). At 20 weeks, the fundus is typically at the level of the
= = = = = = = = = = = = =
umbilicus, measuring approximately 20 cm. Significant
= = = = = = =
discrepancies require further evaluation such as ultrasound .
= = = = = = = =
Cognitive Level: Application | Exam Domain: Antepartum
= = = = = = =
=
2. A client at 8 weeks gestation tells the nurse, "I'm not sure I
= = = = = = = = = = = = =
want to continue with this pregnancy." What is the nurse's
= = = = = = = = = =
BEST response? = =
• A) "You should discuss this with the baby's father."
= = = = = = = = =
• B) "Tell me more about how you are feeling."
= = = = = = = = =
• C) "Don't worry; most women feel this way at first."
= = = = = = = = = =
• D) "You need to make a decision soon before it's too late."
= = = = = = = = = = = =
Answer: B = =
,Rationale: This open- = =
ended statement allows the client to express her feelings and
= = = = = = = = = =
concerns without judgment. It demonstrates therapeutic
= = = = = =
communication and provides an opportunity for the nurse to assess
= = = = = = = = = =
for risk factors such as depression, lack of support, or ambivalence .
= = = = = = = = = = = =
The nurse should never dismiss feelings or rush the decision-
= = = = = = = = =
making process. = =
Cognitive Level: Application | Exam
= = = = =
Domain: Antepartum/Therapeutic Communication
= = =
=
3. A nurse is teaching a primigravida about expected body
= = = = = = = = =
changes during the first trimester. Which findings should the
= = = = = = = = =
nurse include? (Select All That Apply)
= = = = = =
• A) Urinary frequency
= = =
• B) Quickening
= =
• C) Breast tenderness
= = =
• D) Nausea and vomiting
= = = =
• E) Braxton Hicks contractions
= = = =
Answer: A, C, D = = = =
, Rationale: First trimester changes (weeks 1-
= = = = =
12) include urinary frequency (due to hormonal changes and
= = = = = = = = =
uterine pressure on bladder), breast tenderness (from increased
= = = = = = = =
estrogen and progesterone), and nausea/vomiting (morning
= = = = = =
sickness) . Quickening (first fetal movements) is typically felt at 18-
= = = = = = = = = =
20 weeks (second trimester) . Braxton Hicks contractions usually
= = = = = = = = =
begin in the second or third trimester .
= = = = = = = =
Cognitive Level: Comprehension | Exam Domain: Antepartum
= = = = = = =
=
4. At 36 weeks gestation, a client asks the nurse why she is havi
= = = = = = = = = = = =
ng difficulty breathing. What is the MOST accurate explanatio
= = = = = = = =
n? =
• A) "The baby has dropped into the pelvis, making it easier to
= = = = = = = = = = = =
breathe." =
• B) "Your uterus is pushing up against your diaphragm."
= = = = = = = = =
• C) "You may have developed asthma during pregnancy."
= = = = = = = =
• D) "This is a sign of preeclampsia."
= = = = = = =
Answer: B = =
