NUR 202/NUR202 Exam 3 V2 | Maternal-
Newborn Nursing Q&A with Rationale |
Fortis College
1. A nurse is assessing a client at 34 weeks of gestation who has a prescription for magnesium
sulfate. Which of the following findings should the nurse report to the provider as a sign of
toxicity?
A. Blood pressure of 140/90 mmHg
B. Urinary output of 40 mL/hr
C. Respiratory rate of 10/min
D. Deep tendon reflexes of 2+
Correct Answer: C
Expert Explanation: A respiratory rate of less than 12/min is a primary indicator of
magnesium sulfate toxicity. The nurse must also monitor for the loss of deep tendon
reflexes and a significant decrease in urinary output. If toxicity is suspected, the infusion
should be stopped immediately and calcium gluconate should be administered as the
antidote.
2. A nurse is caring for a client who is in labor and has a suspected placenta previa. Which of
the following actions is contraindicated for this client?
A. Monitoring fetal heart rate
,B. Performing a vaginal examination
C. Initiating an intravenous access
D. Checking maternal vital signs
Correct Answer: B
Expert Explanation: Performing a vaginal examination in a client with placenta previa can
cause severe maternal hemorrhage by puncturing the placenta. Painless, bright red vaginal
bleeding is the classic sign of this condition. The nurse should focus on monitoring the fetus
and prepared for a potential cesarean birth.
3. A nurse is reviewing the laboratory results for a client who is at 32 weeks of gestation and
has preeclampsia. Which of the following findings is characteristic of HELLP syndrome?
A. Increased hemoglobin
B. Elevated platelets
C. Low serum creatinine
D. Elevated liver enzymes (AST and ALT)
Correct Answer: D
Expert Explanation: HELLP syndrome stands for Hemolysis, Elevated Liver enzymes, and
Low Platelets. Elevated AST and ALT indicate liver dysfunction, which is a hallmark of this
severe complication of preeclampsia. Patients with this syndrome require intensive
monitoring for multi-organ failure and disseminated intravascular coagulation.
, 4. A nurse is caring for a client in the active phase of labor who has umbilical cord prolapse.
Which of the following positions should the nurse assist the client into?
A. Semi-Fowler’s
B. Knee-chest position
C. Supine with a wedge
D. Lithotomy position
Correct Answer: B
Expert Explanation: The knee-chest position uses gravity to shift the fetus off the
umbilical cord, thereby restoring blood flow and oxygen to the fetus. Alternatively, the
nurse can use a gloved hand to manually lift the fetal presenting part off the cord. This is a
medical emergency that usually requires an immediate cesarean delivery.
5. A nurse is assessing a client 2 hours postpartum and notes that the fundus is boggy and
displaced to the right. Which of the following actions should the nurse take first?
A. Assist the client to void
B. Administer oxytocin
C. Perform fundal massage
D. Call the healthcare provider
Correct Answer: A
Newborn Nursing Q&A with Rationale |
Fortis College
1. A nurse is assessing a client at 34 weeks of gestation who has a prescription for magnesium
sulfate. Which of the following findings should the nurse report to the provider as a sign of
toxicity?
A. Blood pressure of 140/90 mmHg
B. Urinary output of 40 mL/hr
C. Respiratory rate of 10/min
D. Deep tendon reflexes of 2+
Correct Answer: C
Expert Explanation: A respiratory rate of less than 12/min is a primary indicator of
magnesium sulfate toxicity. The nurse must also monitor for the loss of deep tendon
reflexes and a significant decrease in urinary output. If toxicity is suspected, the infusion
should be stopped immediately and calcium gluconate should be administered as the
antidote.
2. A nurse is caring for a client who is in labor and has a suspected placenta previa. Which of
the following actions is contraindicated for this client?
A. Monitoring fetal heart rate
,B. Performing a vaginal examination
C. Initiating an intravenous access
D. Checking maternal vital signs
Correct Answer: B
Expert Explanation: Performing a vaginal examination in a client with placenta previa can
cause severe maternal hemorrhage by puncturing the placenta. Painless, bright red vaginal
bleeding is the classic sign of this condition. The nurse should focus on monitoring the fetus
and prepared for a potential cesarean birth.
3. A nurse is reviewing the laboratory results for a client who is at 32 weeks of gestation and
has preeclampsia. Which of the following findings is characteristic of HELLP syndrome?
A. Increased hemoglobin
B. Elevated platelets
C. Low serum creatinine
D. Elevated liver enzymes (AST and ALT)
Correct Answer: D
Expert Explanation: HELLP syndrome stands for Hemolysis, Elevated Liver enzymes, and
Low Platelets. Elevated AST and ALT indicate liver dysfunction, which is a hallmark of this
severe complication of preeclampsia. Patients with this syndrome require intensive
monitoring for multi-organ failure and disseminated intravascular coagulation.
, 4. A nurse is caring for a client in the active phase of labor who has umbilical cord prolapse.
Which of the following positions should the nurse assist the client into?
A. Semi-Fowler’s
B. Knee-chest position
C. Supine with a wedge
D. Lithotomy position
Correct Answer: B
Expert Explanation: The knee-chest position uses gravity to shift the fetus off the
umbilical cord, thereby restoring blood flow and oxygen to the fetus. Alternatively, the
nurse can use a gloved hand to manually lift the fetal presenting part off the cord. This is a
medical emergency that usually requires an immediate cesarean delivery.
5. A nurse is assessing a client 2 hours postpartum and notes that the fundus is boggy and
displaced to the right. Which of the following actions should the nurse take first?
A. Assist the client to void
B. Administer oxytocin
C. Perform fundal massage
D. Call the healthcare provider
Correct Answer: A
