NUR 2633/NUR2633 Exam 2 V1 | Maternal
Child Health Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is monitoring a client receiving Magnesium Sulfate for preeclampsia. Which of the
following findings should the nurse identify as a priority to report to the provider?
A. Urine output of 40 mL/hr
B. Respiratory rate of 10 breaths per minute
C. Absent clonus in the lower extremities
D. Serum magnesium level of 6 mg/dL
Correct Answer: B
Rationale: A respiratory rate of less than 12 breaths per minute is a classic sign of
magnesium toxicity. The nurse must immediately stop the infusion and prepare the
antidote, calcium gluconate. While a magnesium level of 6 mg/dL is within the therapeutic
range (4-7 mg/dL), respiratory depression indicates a life-threatening complication that
takes priority.
2. A nurse is assessing a client who is 4 hours postpartum and notes a boggy uterus that is
displaced to the right of the midline. Which action should the nurse take first?
A. Administer oxytocin 10 units IM
B. Assist the client to the bathroom to void
,C. Perform vigorous fundal massage
D. Notify the provider of potential hemorrhage
Correct Answer: B
Rationale: A uterus that is displaced to the right and is boggy usually indicates a distended
bladder. A full bladder prevents the uterus from contracting effectively, which increases the
risk of postpartum hemorrhage. Assisting the client to void is the first-line nursing
intervention to allow the uterus to return to the midline and contract.
3. Which of the following medications should the nurse anticipate administering to a client in
preterm labor at 30 weeks of gestation to promote fetal lung maturity?
A. Terbutaline
B. Indomethacin
C. Betamethasone
D. Nifedipine
Correct Answer: C
Rationale: Betamethasone is a corticosteroid administered to the mother in preterm labor
to stimulate the production of surfactant in the fetal lungs. This helps prevent Respiratory
Distress Syndrome (RDS) in the neonate after delivery. It is typically given in two doses 24
hours apart when delivery is anticipated between 24 and 34 weeks of gestation.
, 4. A nurse is evaluating a fetal monitor strip and notes late decelerations. Which of the
following is the most likely cause of this finding?
A. Fetal sleep cycle
B. Fetal head compression
C. Umbilical cord compression
D. Uteroplacental insufficiency
Correct Answer: D
Rationale: Late decelerations are caused by uteroplacental insufficiency, meaning the fetus
is not receiving adequate oxygen during contractions. This is a non-reassuring sign that
requires immediate nursing interventions such as repositioning the mother and providing
oxygen. Early decelerations are caused by head compression, and variable decelerations
are caused by cord compression.
5. A nurse is caring for a client with suspected abruptio placentae. Which clinical finding is
most characteristic of this condition?
A. Painless, bright red vaginal bleeding
B. Soft, non-tender abdomen
C. A rigid, board-like abdomen with severe pain
D. Increased fetal movement
Correct Answer: C
Child Health Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is monitoring a client receiving Magnesium Sulfate for preeclampsia. Which of the
following findings should the nurse identify as a priority to report to the provider?
A. Urine output of 40 mL/hr
B. Respiratory rate of 10 breaths per minute
C. Absent clonus in the lower extremities
D. Serum magnesium level of 6 mg/dL
Correct Answer: B
Rationale: A respiratory rate of less than 12 breaths per minute is a classic sign of
magnesium toxicity. The nurse must immediately stop the infusion and prepare the
antidote, calcium gluconate. While a magnesium level of 6 mg/dL is within the therapeutic
range (4-7 mg/dL), respiratory depression indicates a life-threatening complication that
takes priority.
2. A nurse is assessing a client who is 4 hours postpartum and notes a boggy uterus that is
displaced to the right of the midline. Which action should the nurse take first?
A. Administer oxytocin 10 units IM
B. Assist the client to the bathroom to void
,C. Perform vigorous fundal massage
D. Notify the provider of potential hemorrhage
Correct Answer: B
Rationale: A uterus that is displaced to the right and is boggy usually indicates a distended
bladder. A full bladder prevents the uterus from contracting effectively, which increases the
risk of postpartum hemorrhage. Assisting the client to void is the first-line nursing
intervention to allow the uterus to return to the midline and contract.
3. Which of the following medications should the nurse anticipate administering to a client in
preterm labor at 30 weeks of gestation to promote fetal lung maturity?
A. Terbutaline
B. Indomethacin
C. Betamethasone
D. Nifedipine
Correct Answer: C
Rationale: Betamethasone is a corticosteroid administered to the mother in preterm labor
to stimulate the production of surfactant in the fetal lungs. This helps prevent Respiratory
Distress Syndrome (RDS) in the neonate after delivery. It is typically given in two doses 24
hours apart when delivery is anticipated between 24 and 34 weeks of gestation.
, 4. A nurse is evaluating a fetal monitor strip and notes late decelerations. Which of the
following is the most likely cause of this finding?
A. Fetal sleep cycle
B. Fetal head compression
C. Umbilical cord compression
D. Uteroplacental insufficiency
Correct Answer: D
Rationale: Late decelerations are caused by uteroplacental insufficiency, meaning the fetus
is not receiving adequate oxygen during contractions. This is a non-reassuring sign that
requires immediate nursing interventions such as repositioning the mother and providing
oxygen. Early decelerations are caused by head compression, and variable decelerations
are caused by cord compression.
5. A nurse is caring for a client with suspected abruptio placentae. Which clinical finding is
most characteristic of this condition?
A. Painless, bright red vaginal bleeding
B. Soft, non-tender abdomen
C. A rigid, board-like abdomen with severe pain
D. Increased fetal movement
Correct Answer: C
