NUR 2633/NUR2633 Exam 3 V3 | Maternal
Child Health Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is caring for a client in the first stage of labor and notes a fetal heart rate (FHR)
pattern of late decelerations. Which of the following actions should the nurse take first?
A. Increase the rate of the intravenous infusion.
B. Assist the client to a side-lying position.
C. Administer oxygen via a nonrebreather mask.
D. Document the findings as a normal variation.
Correct Answer: B
Rationale: Late decelerations are indicative of uteroplacental insufficiency and require
immediate intervention to improve oxygenation. Positioning the client on her side relieves
pressure on the vena cava and improves blood flow to the placenta. This is the priority
action before advancing to oxygen administration or increasing fluids.
2. A nurse is assessing a client who is 2 hours postpartum and identifies that the fundus is
boggy and displaced to the right. Which of the following interventions is appropriate?
A. Assist the client to empty her bladder.
B. Administer methylergonovine as prescribed.
C. Perform vigorous fundal massage.
,D. Place the client in Trendelenburg position.
Correct Answer: A
Rationale: A fundus that is displaced to the side, typically the right, is a classic sign of a
distended bladder. A full bladder prevents the uterus from contracting efficiently, which
increases the risk of postpartum hemorrhage. Assisting the client to void allows the uterus
to return to the midline and firm up.
3. A nurse is monitoring a client receiving magnesium sulfate for the treatment of
preeclampsia. Which of the following findings should be reported to the provider
immediately?
A. Respiratory rate of 10 breaths per minute.
B. Urinary output of 40 mL/hr.
C. Flushing and a feeling of warmth.
D. Deep tendon reflexes of 2+.
Correct Answer: A
Rationale: Magnesium sulfate is a central nervous system depressant used to prevent
seizures, but it can cause respiratory depression if toxicity occurs. A respiratory rate below
12 breaths per minute is a critical sign of toxicity that necessitates stopping the infusion.
The nurse should also prepare the antidote, calcium gluconate, for administration.
, 4. A nurse is providing discharge teaching to a mother of a newborn who had a circumcision
with a Gomco clamp. Which of the following instructions should the nurse include?
A. Clean the area with soap and water every 4 hours.
B. Gently wipe away any yellow exudate that forms.
C. Apply petroleum jelly to the glans with each diaper change.
D. Ensure the diaper is fastened tightly to provide pressure.
Correct Answer: C
Rationale: Petroleum jelly should be applied to the circumcision site for at least 24 hours
to prevent the glans from sticking to the diaper. Yellow exudate is a normal part of the
healing process and should not be removed as doing so can cause bleeding. The diaper
should be applied loosely to avoid putting unnecessary pressure on the surgical site.
5. A nurse is assessing a newborn 1 hour after birth. Which of the following findings requires
immediate intervention?
A. Acrocyanosis of the hands and feet.
B. Heart rate of 140 beats per minute.
C. Nasal flaring and chest retractions.
D. Generalized petechiae over the trunk.
Correct Answer: C
Child Health Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is caring for a client in the first stage of labor and notes a fetal heart rate (FHR)
pattern of late decelerations. Which of the following actions should the nurse take first?
A. Increase the rate of the intravenous infusion.
B. Assist the client to a side-lying position.
C. Administer oxygen via a nonrebreather mask.
D. Document the findings as a normal variation.
Correct Answer: B
Rationale: Late decelerations are indicative of uteroplacental insufficiency and require
immediate intervention to improve oxygenation. Positioning the client on her side relieves
pressure on the vena cava and improves blood flow to the placenta. This is the priority
action before advancing to oxygen administration or increasing fluids.
2. A nurse is assessing a client who is 2 hours postpartum and identifies that the fundus is
boggy and displaced to the right. Which of the following interventions is appropriate?
A. Assist the client to empty her bladder.
B. Administer methylergonovine as prescribed.
C. Perform vigorous fundal massage.
,D. Place the client in Trendelenburg position.
Correct Answer: A
Rationale: A fundus that is displaced to the side, typically the right, is a classic sign of a
distended bladder. A full bladder prevents the uterus from contracting efficiently, which
increases the risk of postpartum hemorrhage. Assisting the client to void allows the uterus
to return to the midline and firm up.
3. A nurse is monitoring a client receiving magnesium sulfate for the treatment of
preeclampsia. Which of the following findings should be reported to the provider
immediately?
A. Respiratory rate of 10 breaths per minute.
B. Urinary output of 40 mL/hr.
C. Flushing and a feeling of warmth.
D. Deep tendon reflexes of 2+.
Correct Answer: A
Rationale: Magnesium sulfate is a central nervous system depressant used to prevent
seizures, but it can cause respiratory depression if toxicity occurs. A respiratory rate below
12 breaths per minute is a critical sign of toxicity that necessitates stopping the infusion.
The nurse should also prepare the antidote, calcium gluconate, for administration.
, 4. A nurse is providing discharge teaching to a mother of a newborn who had a circumcision
with a Gomco clamp. Which of the following instructions should the nurse include?
A. Clean the area with soap and water every 4 hours.
B. Gently wipe away any yellow exudate that forms.
C. Apply petroleum jelly to the glans with each diaper change.
D. Ensure the diaper is fastened tightly to provide pressure.
Correct Answer: C
Rationale: Petroleum jelly should be applied to the circumcision site for at least 24 hours
to prevent the glans from sticking to the diaper. Yellow exudate is a normal part of the
healing process and should not be removed as doing so can cause bleeding. The diaper
should be applied loosely to avoid putting unnecessary pressure on the surgical site.
5. A nurse is assessing a newborn 1 hour after birth. Which of the following findings requires
immediate intervention?
A. Acrocyanosis of the hands and feet.
B. Heart rate of 140 beats per minute.
C. Nasal flaring and chest retractions.
D. Generalized petechiae over the trunk.
Correct Answer: C
