NUR 202/NUR202 Exam 1 V3 | Maternal-
Newborn Nursing Q&A with Rationale |
Fortis College
1. A nurse is calculating a client’s expected date of delivery (EDD) using Naegele’s rule. The
client’s last menstrual period (LMP) began on May 10th. Which of the following dates should
the nurse identify as the client’s EDD?
A. August 17th
B. February 3rd
C. February 17th
D. January 17th
Correct Answer: C
Expert Explanation: To calculate the EDD using Naegele’s rule, subtract 3 months and add
7 days to the first day of the last menstrual period. For an LMP starting May 10th,
subtracting 3 months brings us to February, and adding 7 days brings us to February 17th.
This method assumes a standard 28-day cycle and is the most common way to estimate the
due date in clinical practice.
2. A nurse is assessing a client who is at 30 weeks of gestation. Which of the following
findings is considered a ‘positive’ sign of pregnancy?
A. Amenorrhea
,B. Positive pregnancy test
C. Quickening
D. Fetal heart tones heard by Doppler
Correct Answer: D
Expert Explanation: Positive signs of pregnancy are those that can be attributed only to
the presence of a fetus, such as hearing fetal heart tones or visualizing the fetus via
ultrasound. Amenorrhea and quickening are presumptive signs, which are subjective
experiences reported by the client. A positive pregnancy test is considered a probable sign
because other conditions can increase hCG levels, making it objective but not definitive of a
live fetus.
3. A nurse is caring for a client in the first stage of labor and notes a fetal heart rate (FHR)
pattern showing late decelerations. Which of the following actions should the nurse take
first?
A. Administer oxygen via non-rebreather mask at 10 L/min
B. Increase the rate of the IV maintenance fluids
C. Turn the client onto her left side
D. Notify the healthcare provider
Correct Answer: C
,Expert Explanation: Late decelerations indicate uteroplacental insufficiency and require
immediate intervention to improve oxygenation to the fetus. The first priority is to
reposition the client, usually to the left side, to displace the uterus from the vena cava and
improve blood flow. After repositioning, the nurse should provide oxygen, increase IV
fluids, and notify the provider while continuing to monitor the FHR.
4. A nurse is assessing a newborn 1 hour after birth. The nurse notes the newborn has a
respiratory rate of 52 breaths/min, occasional grunting, and nasal flaring. Which of the
following actions should the nurse take?
A. Document the findings as normal newborn transition
B. Place the newborn in a radiant warmer and monitor
C. Initiate breastfeeding to stabilize the respiratory rate
D. Assess for signs of respiratory distress and notify the provider
Correct Answer: D
Expert Explanation: While a respiratory rate of 52 is within the normal range of 30 to 60
breaths/min, grunting and nasal flaring are abnormal signs of respiratory distress. These
findings suggest the newborn is working harder than normal to maintain gas exchange and
require immediate evaluation. The nurse must prioritize monitoring the infant’s oxygen
saturation and notifying the healthcare provider for further intervention.
, 5. A client at 34 weeks of gestation is diagnosed with mild preeclampsia. Which of the
following instructions should the nurse include in the teaching plan for home care?
A. Report a weight gain of more than 2 lbs in 24 hours
B. Restrict fluid intake to 1 liter per day
C. Perform vigorous aerobic exercise daily
D. Maintain a low-protein diet
Correct Answer: A
Expert Explanation: Rapid weight gain in a client with preeclampsia is a sign of worsening
edema and fluid retention, which must be reported to the provider immediately. Fluid
restriction is generally not recommended for mild preeclampsia, as adequate hydration is
necessary for renal perfusion. Clients are usually advised to rest more frequently rather
than engage in vigorous exercise to prevent exacerbating hypertension.
6. A nurse is performing a physical assessment of a newborn and observes small, white
nodules on the roof of the newborn’s mouth. The nurse should document these as:
A. Epstein pearls
B. Thrush
C. Milium
D. Mongolian spots
Correct Answer: A
Newborn Nursing Q&A with Rationale |
Fortis College
1. A nurse is calculating a client’s expected date of delivery (EDD) using Naegele’s rule. The
client’s last menstrual period (LMP) began on May 10th. Which of the following dates should
the nurse identify as the client’s EDD?
A. August 17th
B. February 3rd
C. February 17th
D. January 17th
Correct Answer: C
Expert Explanation: To calculate the EDD using Naegele’s rule, subtract 3 months and add
7 days to the first day of the last menstrual period. For an LMP starting May 10th,
subtracting 3 months brings us to February, and adding 7 days brings us to February 17th.
This method assumes a standard 28-day cycle and is the most common way to estimate the
due date in clinical practice.
2. A nurse is assessing a client who is at 30 weeks of gestation. Which of the following
findings is considered a ‘positive’ sign of pregnancy?
A. Amenorrhea
,B. Positive pregnancy test
C. Quickening
D. Fetal heart tones heard by Doppler
Correct Answer: D
Expert Explanation: Positive signs of pregnancy are those that can be attributed only to
the presence of a fetus, such as hearing fetal heart tones or visualizing the fetus via
ultrasound. Amenorrhea and quickening are presumptive signs, which are subjective
experiences reported by the client. A positive pregnancy test is considered a probable sign
because other conditions can increase hCG levels, making it objective but not definitive of a
live fetus.
3. A nurse is caring for a client in the first stage of labor and notes a fetal heart rate (FHR)
pattern showing late decelerations. Which of the following actions should the nurse take
first?
A. Administer oxygen via non-rebreather mask at 10 L/min
B. Increase the rate of the IV maintenance fluids
C. Turn the client onto her left side
D. Notify the healthcare provider
Correct Answer: C
,Expert Explanation: Late decelerations indicate uteroplacental insufficiency and require
immediate intervention to improve oxygenation to the fetus. The first priority is to
reposition the client, usually to the left side, to displace the uterus from the vena cava and
improve blood flow. After repositioning, the nurse should provide oxygen, increase IV
fluids, and notify the provider while continuing to monitor the FHR.
4. A nurse is assessing a newborn 1 hour after birth. The nurse notes the newborn has a
respiratory rate of 52 breaths/min, occasional grunting, and nasal flaring. Which of the
following actions should the nurse take?
A. Document the findings as normal newborn transition
B. Place the newborn in a radiant warmer and monitor
C. Initiate breastfeeding to stabilize the respiratory rate
D. Assess for signs of respiratory distress and notify the provider
Correct Answer: D
Expert Explanation: While a respiratory rate of 52 is within the normal range of 30 to 60
breaths/min, grunting and nasal flaring are abnormal signs of respiratory distress. These
findings suggest the newborn is working harder than normal to maintain gas exchange and
require immediate evaluation. The nurse must prioritize monitoring the infant’s oxygen
saturation and notifying the healthcare provider for further intervention.
, 5. A client at 34 weeks of gestation is diagnosed with mild preeclampsia. Which of the
following instructions should the nurse include in the teaching plan for home care?
A. Report a weight gain of more than 2 lbs in 24 hours
B. Restrict fluid intake to 1 liter per day
C. Perform vigorous aerobic exercise daily
D. Maintain a low-protein diet
Correct Answer: A
Expert Explanation: Rapid weight gain in a client with preeclampsia is a sign of worsening
edema and fluid retention, which must be reported to the provider immediately. Fluid
restriction is generally not recommended for mild preeclampsia, as adequate hydration is
necessary for renal perfusion. Clients are usually advised to rest more frequently rather
than engage in vigorous exercise to prevent exacerbating hypertension.
6. A nurse is performing a physical assessment of a newborn and observes small, white
nodules on the roof of the newborn’s mouth. The nurse should document these as:
A. Epstein pearls
B. Thrush
C. Milium
D. Mongolian spots
Correct Answer: A
