NUR 202/NUR202 Exam 2 V1 | Maternal-
Newborn Nursing Q&A with Rationale |
Fortis College
1. A nurse is monitoring a client in the active phase of labor and notes a fetal heart rate (FHR)
pattern of late decelerations. Which of the following actions should the nurse prioritize?
A. Administer oxygen at 8 to 10 L/min via nonrebreather mask.
B. Position the client in a lateral or side-lying position.
C. Increase the rate of the maintenance intravenous fluid.
D. Perform a vaginal examination to check for cord prolapse.
Correct Answer: B
Expert Explanation: The first priority when late decelerations are identified is to improve
placental perfusion by changing the client’s position to a lateral side. Late decelerations are
indicative of uteroplacental insufficiency, which can be exacerbated by supine hypotension.
After positioning, the nurse should follow with other intrauterine resuscitation measures
such as oxygen administration and fluid boluses.
2. A client at 32 weeks of gestation is admitted with preterm labor. The provider orders
betamethasone 12 mg IM. What is the primary purpose of this medication?
A. To stop uterine contractions and prevent delivery.
B. To prevent group B streptococcus infection in the neonate.
,C. To enhance fetal lung maturity and surfactant production.
D. To increase maternal blood glucose levels for fetal energy.
Correct Answer: C
Expert Explanation: Betamethasone is a corticosteroid administered to women in
preterm labor between 24 and 34 weeks of gestation. It stimulates the production of
surfactant in the fetal lungs, which reduces the risk and severity of respiratory distress
syndrome (RDS) in the newborn. This intervention is crucial for improving neonatal
outcomes in the event of an early delivery.
3. The nurse is caring for a client receiving magnesium sulfate for preeclampsia. Which
assessment finding should the nurse report to the provider immediately?
A. Deep tendon reflexes (DTR) of 2+.
B. Blood pressure of 150/94 mmHg.
C. Urinary output of 20 mL/hr over the last 2 hours.
D. Respiratory rate of 14 breaths per minute.
Correct Answer: C
Expert Explanation: A urinary output of less than 30 mL/hr is a significant finding that
may indicate declining renal function or impending magnesium toxicity. Magnesium sulfate
is excreted primarily by the kidneys, so decreased output leads to toxic accumulation. The
nurse must monitor output, reflexes, and respirations closely to ensure the safety of the
client.
,4. A client is in the transition phase of the first stage of labor. Which clinical manifestation is
most characteristic of this phase?
A. The client is sociable and talkative about the birth plan.
B. The cervix is dilated 2 to 3 cm.
C. Contractions are occurring every 5 to 10 minutes.
D. The client expresses a loss of control and irritability.
Correct Answer: D
Expert Explanation: The transition phase, occurring when the cervix is dilated 8 to 10 cm,
is often characterized by intense contractions and maternal psychological shifts. Clients
frequently experience a sense of panic, irritability, and may declare they ‘cannot do this’
anymore. This phase is the most difficult but shortest part of the first stage of labor.
5. A nurse is evaluating an electronic fetal monitor strip and observes variable decelerations.
What is the most likely cause of this FHR pattern?
A. Head compression during contractions.
B. Umbilical cord compression.
C. Uteroplacental insufficiency.
D. Fetal sleep state.
Correct Answer: B
, Expert Explanation: Variable decelerations are abrupt decreases in FHR that are typically
shaped like a V, U, or W, and they are caused by umbilical cord compression. Unlike early or
late decelerations, variables are not always synchronized with contractions. Nursing
interventions include changing the maternal position to relieve pressure on the cord.
6. A client at 38 weeks of gestation presents with painless, bright red vaginal bleeding. Which
of the following conditions should the nurse suspect?
A. Placenta previa.
B. Abruptio placentae.
C. Uterine rupture.
D. Preterm labor.
Correct Answer: A
Expert Explanation: Painless, bright red vaginal bleeding in the third trimester is the
classic sign of placenta previa. This occurs when the placenta covers the internal os of the
cervix, either partially or completely. In contrast, abruptio placentae typically presents
with painful, dark red bleeding and uterine rigidity.
7. A nurse is teaching a client about the purpose of the Non-Stress Test (NST). Which
statement by the client indicates an understanding of the procedure?
A. ‘The test will show how my baby reacts to uterine contractions.’
B. ‘The test monitors my baby’s heart rate in response to movement.’
C. ‘I will need to be NPO for 4 hours before the test starts.’
Newborn Nursing Q&A with Rationale |
Fortis College
1. A nurse is monitoring a client in the active phase of labor and notes a fetal heart rate (FHR)
pattern of late decelerations. Which of the following actions should the nurse prioritize?
A. Administer oxygen at 8 to 10 L/min via nonrebreather mask.
B. Position the client in a lateral or side-lying position.
C. Increase the rate of the maintenance intravenous fluid.
D. Perform a vaginal examination to check for cord prolapse.
Correct Answer: B
Expert Explanation: The first priority when late decelerations are identified is to improve
placental perfusion by changing the client’s position to a lateral side. Late decelerations are
indicative of uteroplacental insufficiency, which can be exacerbated by supine hypotension.
After positioning, the nurse should follow with other intrauterine resuscitation measures
such as oxygen administration and fluid boluses.
2. A client at 32 weeks of gestation is admitted with preterm labor. The provider orders
betamethasone 12 mg IM. What is the primary purpose of this medication?
A. To stop uterine contractions and prevent delivery.
B. To prevent group B streptococcus infection in the neonate.
,C. To enhance fetal lung maturity and surfactant production.
D. To increase maternal blood glucose levels for fetal energy.
Correct Answer: C
Expert Explanation: Betamethasone is a corticosteroid administered to women in
preterm labor between 24 and 34 weeks of gestation. It stimulates the production of
surfactant in the fetal lungs, which reduces the risk and severity of respiratory distress
syndrome (RDS) in the newborn. This intervention is crucial for improving neonatal
outcomes in the event of an early delivery.
3. The nurse is caring for a client receiving magnesium sulfate for preeclampsia. Which
assessment finding should the nurse report to the provider immediately?
A. Deep tendon reflexes (DTR) of 2+.
B. Blood pressure of 150/94 mmHg.
C. Urinary output of 20 mL/hr over the last 2 hours.
D. Respiratory rate of 14 breaths per minute.
Correct Answer: C
Expert Explanation: A urinary output of less than 30 mL/hr is a significant finding that
may indicate declining renal function or impending magnesium toxicity. Magnesium sulfate
is excreted primarily by the kidneys, so decreased output leads to toxic accumulation. The
nurse must monitor output, reflexes, and respirations closely to ensure the safety of the
client.
,4. A client is in the transition phase of the first stage of labor. Which clinical manifestation is
most characteristic of this phase?
A. The client is sociable and talkative about the birth plan.
B. The cervix is dilated 2 to 3 cm.
C. Contractions are occurring every 5 to 10 minutes.
D. The client expresses a loss of control and irritability.
Correct Answer: D
Expert Explanation: The transition phase, occurring when the cervix is dilated 8 to 10 cm,
is often characterized by intense contractions and maternal psychological shifts. Clients
frequently experience a sense of panic, irritability, and may declare they ‘cannot do this’
anymore. This phase is the most difficult but shortest part of the first stage of labor.
5. A nurse is evaluating an electronic fetal monitor strip and observes variable decelerations.
What is the most likely cause of this FHR pattern?
A. Head compression during contractions.
B. Umbilical cord compression.
C. Uteroplacental insufficiency.
D. Fetal sleep state.
Correct Answer: B
, Expert Explanation: Variable decelerations are abrupt decreases in FHR that are typically
shaped like a V, U, or W, and they are caused by umbilical cord compression. Unlike early or
late decelerations, variables are not always synchronized with contractions. Nursing
interventions include changing the maternal position to relieve pressure on the cord.
6. A client at 38 weeks of gestation presents with painless, bright red vaginal bleeding. Which
of the following conditions should the nurse suspect?
A. Placenta previa.
B. Abruptio placentae.
C. Uterine rupture.
D. Preterm labor.
Correct Answer: A
Expert Explanation: Painless, bright red vaginal bleeding in the third trimester is the
classic sign of placenta previa. This occurs when the placenta covers the internal os of the
cervix, either partially or completely. In contrast, abruptio placentae typically presents
with painful, dark red bleeding and uterine rigidity.
7. A nurse is teaching a client about the purpose of the Non-Stress Test (NST). Which
statement by the client indicates an understanding of the procedure?
A. ‘The test will show how my baby reacts to uterine contractions.’
B. ‘The test monitors my baby’s heart rate in response to movement.’
C. ‘I will need to be NPO for 4 hours before the test starts.’
