,NUR 2513 Exam 3 — Maternal-Child Nursing |
Rasmussen University | 2026/2027 Exam Prep
+ Practice 100 Q&A + Rationales
Q1. A nurse is monitoring a client receiving magnesium sulfate for preeclampsia. Which
finding should the nurse report immediately?
A. Respiratory rate of 14/min
B. Deep tendon reflexes of 2+
C. Urine output of 20 mL/hr
D. Blood pressure of 150/95 mm Hg
Correct Answer: C. Urine output of 20 mL/hr
Rationale: Magnesium sulfate is excreted by the kidneys, so urine output below 30 mL/hr can
lead to toxicity. A respiratory rate of 14/min is within normal limits. Deep tendon reflexes of
2+ are normal. A blood pressure of 150/95 mm Hg is elevated but is not a sign of magnesium
toxicity. The nurse should monitor for respiratory depression, absent reflexes, and oliguria
and hold the infusion if toxicity is suspected.
Key Takeaway: Urine output below 30 mL/hr during magnesium sulfate infusion indicates risk
for toxicity; notify the provider.
Q2. A client in the transition phase of labor is expected to exhibit which manifestation?
A. Dilation of 1 to 3 cm
B. Talkative and excited behavior
C. Contractions every 10 to 15 minutes
D. Frequent urge to push
Correct Answer: D. Frequent urge to push
Rationale: The transition phase occurs at 8 to 10 cm dilation and is the most intense part of
the first stage of labor. Clients often experience an urge to push, irritability, and nausea.
Dilation of 1 to 3 cm indicates the latent phase. Talkative and excited behavior is characteristic
,of the latent phase. Contractions every 10 to 15 minutes indicate early labor. The nurse should
provide support and monitor for signs of imminent birth.
Key Takeaway: Transition phase is 8 to 10 cm dilation with intense contractions and an urge to
push.
Q3. A nurse observes variable decelerations on the fetal monitor. What is the priority action?
A. Increase IV fluid rate
B. Administer oxygen
C. Perform a vaginal exam
D. Assist the client to a side-lying or knee-chest position
Correct Answer: D. Assist the client to a side-lying or knee-chest position
Rationale: Variable decelerations are caused by umbilical cord compression. Repositioning is
the first intervention to relieve pressure. Increasing IV fluids and administering oxygen are
supportive measures. A vaginal exam may be performed to assess for cord prolapse but is not
the first action. The nurse should also discontinue oxytocin if infusing.
Key Takeaway: Reposition the client first for variable decelerations to relieve umbilical cord
compression.
Q4. Which patient is most appropriate for an amnioinfusion?
A. A woman with absent variability
B. A woman with early decelerations
C. A woman with late decelerations
D. A woman with variable decelerations
Correct Answer: D. A woman with variable decelerations
Rationale: Amnioinfusion is used to relieve umbilical cord compression causing variable
decelerations. It involves infusing sterile fluid into the amniotic cavity to cushion the cord.
Absent variability, early decelerations, and late decelerations are not treated with
amnioinfusion. The nurse should monitor for uterine overdistention and infection.
Key Takeaway: Amnioinfusion is used for variable decelerations caused by cord compression.
, Q5. A client at 38 weeks' gestation reports heavy, red vaginal bleeding without contractions.
What should the ultrasound determine?
A. Placenta placement
B. Gestational age
C. Fetal lung maturity
D. Fetal measurement for dating
Correct Answer: A. Placenta placement
Rationale: Painless, bright red bleeding in late pregnancy suggests placenta previa; ultrasound
determines placental location. Gestational age, fetal lung maturity, and fetal measurement
are not the priority for this presentation. The nurse should avoid vaginal examinations and
prepare for possible cesarean delivery.
Key Takeaway: Ultrasound for placental location is the priority with painless late-pregnancy
bleeding.
Q6. A client at 28 weeks' gestation reports painless vaginal bleeding. What is the likely cause?
A. Abruptio placentae
B. Placenta previa
C. Cervical insufficiency
D. Uterine rupture
Correct Answer: B. Placenta previa
Rationale: Placenta previa presents as painless vaginal bleeding in the second or third
trimester. Abruptio placentae typically presents with painful bleeding and a rigid abdomen.
Cervical insufficiency presents with painless cervical dilation without bleeding. Uterine
rupture presents with sudden severe pain and fetal distress. The nurse should avoid vaginal
examinations.
Key Takeaway: Painless vaginal bleeding in late pregnancy suggests placenta previa.
Q7. A cause of abruptio placentae is:
Rasmussen University | 2026/2027 Exam Prep
+ Practice 100 Q&A + Rationales
Q1. A nurse is monitoring a client receiving magnesium sulfate for preeclampsia. Which
finding should the nurse report immediately?
A. Respiratory rate of 14/min
B. Deep tendon reflexes of 2+
C. Urine output of 20 mL/hr
D. Blood pressure of 150/95 mm Hg
Correct Answer: C. Urine output of 20 mL/hr
Rationale: Magnesium sulfate is excreted by the kidneys, so urine output below 30 mL/hr can
lead to toxicity. A respiratory rate of 14/min is within normal limits. Deep tendon reflexes of
2+ are normal. A blood pressure of 150/95 mm Hg is elevated but is not a sign of magnesium
toxicity. The nurse should monitor for respiratory depression, absent reflexes, and oliguria
and hold the infusion if toxicity is suspected.
Key Takeaway: Urine output below 30 mL/hr during magnesium sulfate infusion indicates risk
for toxicity; notify the provider.
Q2. A client in the transition phase of labor is expected to exhibit which manifestation?
A. Dilation of 1 to 3 cm
B. Talkative and excited behavior
C. Contractions every 10 to 15 minutes
D. Frequent urge to push
Correct Answer: D. Frequent urge to push
Rationale: The transition phase occurs at 8 to 10 cm dilation and is the most intense part of
the first stage of labor. Clients often experience an urge to push, irritability, and nausea.
Dilation of 1 to 3 cm indicates the latent phase. Talkative and excited behavior is characteristic
,of the latent phase. Contractions every 10 to 15 minutes indicate early labor. The nurse should
provide support and monitor for signs of imminent birth.
Key Takeaway: Transition phase is 8 to 10 cm dilation with intense contractions and an urge to
push.
Q3. A nurse observes variable decelerations on the fetal monitor. What is the priority action?
A. Increase IV fluid rate
B. Administer oxygen
C. Perform a vaginal exam
D. Assist the client to a side-lying or knee-chest position
Correct Answer: D. Assist the client to a side-lying or knee-chest position
Rationale: Variable decelerations are caused by umbilical cord compression. Repositioning is
the first intervention to relieve pressure. Increasing IV fluids and administering oxygen are
supportive measures. A vaginal exam may be performed to assess for cord prolapse but is not
the first action. The nurse should also discontinue oxytocin if infusing.
Key Takeaway: Reposition the client first for variable decelerations to relieve umbilical cord
compression.
Q4. Which patient is most appropriate for an amnioinfusion?
A. A woman with absent variability
B. A woman with early decelerations
C. A woman with late decelerations
D. A woman with variable decelerations
Correct Answer: D. A woman with variable decelerations
Rationale: Amnioinfusion is used to relieve umbilical cord compression causing variable
decelerations. It involves infusing sterile fluid into the amniotic cavity to cushion the cord.
Absent variability, early decelerations, and late decelerations are not treated with
amnioinfusion. The nurse should monitor for uterine overdistention and infection.
Key Takeaway: Amnioinfusion is used for variable decelerations caused by cord compression.
, Q5. A client at 38 weeks' gestation reports heavy, red vaginal bleeding without contractions.
What should the ultrasound determine?
A. Placenta placement
B. Gestational age
C. Fetal lung maturity
D. Fetal measurement for dating
Correct Answer: A. Placenta placement
Rationale: Painless, bright red bleeding in late pregnancy suggests placenta previa; ultrasound
determines placental location. Gestational age, fetal lung maturity, and fetal measurement
are not the priority for this presentation. The nurse should avoid vaginal examinations and
prepare for possible cesarean delivery.
Key Takeaway: Ultrasound for placental location is the priority with painless late-pregnancy
bleeding.
Q6. A client at 28 weeks' gestation reports painless vaginal bleeding. What is the likely cause?
A. Abruptio placentae
B. Placenta previa
C. Cervical insufficiency
D. Uterine rupture
Correct Answer: B. Placenta previa
Rationale: Placenta previa presents as painless vaginal bleeding in the second or third
trimester. Abruptio placentae typically presents with painful bleeding and a rigid abdomen.
Cervical insufficiency presents with painless cervical dilation without bleeding. Uterine
rupture presents with sudden severe pain and fetal distress. The nurse should avoid vaginal
examinations.
Key Takeaway: Painless vaginal bleeding in late pregnancy suggests placenta previa.
Q7. A cause of abruptio placentae is:
