NUR 202/NUR202 Exam 3 V2 | Maternal-
Newborn Nursing Q&A with Rationale |
Fortis College
1. A nurse is assessing a client in the active phase of the first stage of labor. Which cervical
dilation measurement should the nurse anticipate for this stage?
A. 1 to 3 cm
B. 8 to 10 cm
C. 4 to 7 cm
D. 10 to 12 cm
Correct Answer: C
Expert Explanation: The active phase of labor is defined as cervical dilation between 4
and 7 cm. During this time, the client typically experiences more regular and intense
contractions. It is a critical period where the nurse must monitor for progress and provide
support for pain management.
2. A nurse is reviewing a fetal heart rate tracing and notes variable decelerations. What is the
primary cause of this pattern?
A. Uteroplacental insufficiency
B. Fetal head compression
C. Maternal hypotension
,D. Umbilical cord compression
Correct Answer: D
Expert Explanation: Variable decelerations are caused by compression of the umbilical
cord during contractions or fetal movement. This pattern often appears as a V, U, or W
shape on the electronic fetal monitor. The nurse should prioritize changing the mother’s
position to relieve pressure on the cord.
3. A nurse is preparing to administer Magnesium Sulfate to a client with preeclampsia. Which
of the following findings would indicate toxicity?
A. Respiratory rate of 10/min
B. Urinary output of 50 mL/hr
C. Deep tendon reflexes 2+
D. Maternal heart rate of 90/min
Correct Answer: A
Expert Explanation: A respiratory rate of less than 12/min is a classic sign of magnesium
toxicity. Other signs include the loss of deep tendon reflexes and a significant drop in
urinary output. If toxicity is suspected, the nurse must immediately stop the infusion and
prepare the antidote, calcium gluconate.
4. Which postpartum assessment finding would the nurse consider most concerning 2 hours
after delivery?
A. Lochia rubra with small clots
, B. A boggy uterus that firms with massage
C. A fundus displaced to the right of the midline
D. Serviceable afterpains in a multiparous client
Correct Answer: C
Expert Explanation: A fundus displaced to the right of the midline usually indicates a
distended bladder. A full bladder can prevent the uterus from contracting properly,
increasing the risk of postpartum hemorrhage. The nurse should encourage the client to
void or perform catheterization if necessary.
5. A newborn is assessed at 1 minute after birth. The heart rate is 110, there is a weak cry,
some flexion of extremities, the body is pink with blue hands and feet, and the infant
grimaces when stimulated. What is the Apgar score?
A. 6
B. 5
C. 7
D. 8
Correct Answer: A
Expert Explanation: The score is calculated as follows: Heart rate >100 (2), weak cry (1),
some flexion (1), acrocyanosis (1), and grimace (1), totaling 6. This score suggests that the
Newborn Nursing Q&A with Rationale |
Fortis College
1. A nurse is assessing a client in the active phase of the first stage of labor. Which cervical
dilation measurement should the nurse anticipate for this stage?
A. 1 to 3 cm
B. 8 to 10 cm
C. 4 to 7 cm
D. 10 to 12 cm
Correct Answer: C
Expert Explanation: The active phase of labor is defined as cervical dilation between 4
and 7 cm. During this time, the client typically experiences more regular and intense
contractions. It is a critical period where the nurse must monitor for progress and provide
support for pain management.
2. A nurse is reviewing a fetal heart rate tracing and notes variable decelerations. What is the
primary cause of this pattern?
A. Uteroplacental insufficiency
B. Fetal head compression
C. Maternal hypotension
,D. Umbilical cord compression
Correct Answer: D
Expert Explanation: Variable decelerations are caused by compression of the umbilical
cord during contractions or fetal movement. This pattern often appears as a V, U, or W
shape on the electronic fetal monitor. The nurse should prioritize changing the mother’s
position to relieve pressure on the cord.
3. A nurse is preparing to administer Magnesium Sulfate to a client with preeclampsia. Which
of the following findings would indicate toxicity?
A. Respiratory rate of 10/min
B. Urinary output of 50 mL/hr
C. Deep tendon reflexes 2+
D. Maternal heart rate of 90/min
Correct Answer: A
Expert Explanation: A respiratory rate of less than 12/min is a classic sign of magnesium
toxicity. Other signs include the loss of deep tendon reflexes and a significant drop in
urinary output. If toxicity is suspected, the nurse must immediately stop the infusion and
prepare the antidote, calcium gluconate.
4. Which postpartum assessment finding would the nurse consider most concerning 2 hours
after delivery?
A. Lochia rubra with small clots
, B. A boggy uterus that firms with massage
C. A fundus displaced to the right of the midline
D. Serviceable afterpains in a multiparous client
Correct Answer: C
Expert Explanation: A fundus displaced to the right of the midline usually indicates a
distended bladder. A full bladder can prevent the uterus from contracting properly,
increasing the risk of postpartum hemorrhage. The nurse should encourage the client to
void or perform catheterization if necessary.
5. A newborn is assessed at 1 minute after birth. The heart rate is 110, there is a weak cry,
some flexion of extremities, the body is pink with blue hands and feet, and the infant
grimaces when stimulated. What is the Apgar score?
A. 6
B. 5
C. 7
D. 8
Correct Answer: A
Expert Explanation: The score is calculated as follows: Heart rate >100 (2), weak cry (1),
some flexion (1), acrocyanosis (1), and grimace (1), totaling 6. This score suggests that the
