NUR 202/NUR202 Exam 2 V2 | Maternal-
Newborn Nursing Q&A with Rationale |
Fortis College
1. A nurse is caring for a client who is at 34 weeks of gestation and has a prescription for
magnesium sulfate IV to treat preeclampsia. Which of the following findings should the nurse
report to the provider as a sign of magnesium toxicity?
A. Blood pressure 148/92 mmHg
B. Respiratory rate of 10/min
C. Urinary output of 40 mL/hr
D. Generalized 2+ edema
Correct Answer: B
Expert Explanation: Magnesium sulfate is a central nervous system depressant used to
prevent seizures in preeclampsia. A respiratory rate of less than 12/min is a primary
indicator of magnesium toxicity and requires immediate intervention. The nurse must also
monitor for the loss of deep tendon reflexes and decreased urinary output below 30 mL/hr.
2. A nurse is reviewing the electronic fetal heart rate (FHR) tracing of a client in active labor.
The nurse notes several late decelerations. Which of the following actions should the nurse
take first?
A. Increase the rate of the oxytocin infusion
,B. Reposition the client into a lateral position
C. Perform a vaginal exam to check for cord prolapse
D. Prepare for an immediate vacuum-assisted delivery
Correct Answer: B
Expert Explanation: Late decelerations are caused by uteroplacental insufficiency and are
a non-reassuring FHR pattern. Repositioning the client to a side-lying position is the initial
priority to improve blood flow to the placenta. This nursing action should be followed by
oxygen administration and discontinuing oxytocin if applicable.
3. A nurse is assessing a newborn 1 hour after birth. Which of the following findings should
the nurse report to the provider?
A. Acrocyanosis of the hands and feet
B. Presence of vernix caseosa in skin folds
C. A heart rate of 140 beats per minute
D. Nasal flaring and chest retractions
Correct Answer: D
Expert Explanation: Nasal flaring, chest retractions, and grunting are classic signs of
respiratory distress in a newborn. Acrocyanosis is a normal finding in the first 24 to 48
hours of life due to peripheral circulation adjustment. These respiratory distress signs
,require immediate evaluation to ensure the newborn’s airway and oxygenation are
maintained.
4. A nurse is caring for a client who is in the first stage of labor and has an umbilical cord
prolapse. Which of the following is the priority nursing action?
A. Administer oxygen at 10 L/min via nonrebreather mask
B. Apply sterile saline-soaked gauze to the cord
C. Cover the client to maintain thermoregulation
D. Place the client in a Trendelenburg or knee-chest position
Correct Answer: D
Expert Explanation: Umbilical cord prolapse is a medical emergency because the
presenting part compresses the cord, cutting off fetal oxygen. Placing the client in a
Trendelenburg or knee-chest position uses gravity to shift the fetus off the cord. The nurse
should also apply manual upward pressure on the presenting part until a cesarean section
is performed.
5. A nurse is providing discharge teaching to a client who is postpartum and bottle-feeding
her newborn. Which of the following instructions should the nurse include to prevent breast
engorgement?
A. Apply warm compresses to the breasts several times a day
B. Express small amounts of milk manually if breasts feel full
C. Stimulate the nipples during a shower to promote drainage
, D. Wear a tight-fitting supportive bra or breast binder
Correct Answer: D
Expert Explanation: For bottle-feeding mothers, the goal is to suppress lactation and
prevent stimulation. Wearing a tight-fitting bra continuously for the first 72 hours helps
suppress milk production through pressure. The client should also avoid heat and nipple
stimulation, which would otherwise trigger the let-down reflex.
6. A nurse is assessing a client who is at 32 weeks of gestation and reports painless, bright red
vaginal bleeding. Which of the following conditions should the nurse suspect?
A. Abruptio placentae
B. Preterm labor
C. Placenta previa
D. Threatened abortion
Correct Answer: C
Expert Explanation: Placenta previa is characterized by painless, bright red vaginal
bleeding during the second or third trimester. This occurs because the placenta is
implanted over or near the internal cervical os. In contrast, abruptio placentae typically
involves dark red bleeding and significant abdominal pain.
7. A nurse is administering Rho(D) immune globulin to a client. Which of the following clients
should receive this medication?
A. An Rh-negative mother who has an Rh-positive newborn
Newborn Nursing Q&A with Rationale |
Fortis College
1. A nurse is caring for a client who is at 34 weeks of gestation and has a prescription for
magnesium sulfate IV to treat preeclampsia. Which of the following findings should the nurse
report to the provider as a sign of magnesium toxicity?
A. Blood pressure 148/92 mmHg
B. Respiratory rate of 10/min
C. Urinary output of 40 mL/hr
D. Generalized 2+ edema
Correct Answer: B
Expert Explanation: Magnesium sulfate is a central nervous system depressant used to
prevent seizures in preeclampsia. A respiratory rate of less than 12/min is a primary
indicator of magnesium toxicity and requires immediate intervention. The nurse must also
monitor for the loss of deep tendon reflexes and decreased urinary output below 30 mL/hr.
2. A nurse is reviewing the electronic fetal heart rate (FHR) tracing of a client in active labor.
The nurse notes several late decelerations. Which of the following actions should the nurse
take first?
A. Increase the rate of the oxytocin infusion
,B. Reposition the client into a lateral position
C. Perform a vaginal exam to check for cord prolapse
D. Prepare for an immediate vacuum-assisted delivery
Correct Answer: B
Expert Explanation: Late decelerations are caused by uteroplacental insufficiency and are
a non-reassuring FHR pattern. Repositioning the client to a side-lying position is the initial
priority to improve blood flow to the placenta. This nursing action should be followed by
oxygen administration and discontinuing oxytocin if applicable.
3. A nurse is assessing a newborn 1 hour after birth. Which of the following findings should
the nurse report to the provider?
A. Acrocyanosis of the hands and feet
B. Presence of vernix caseosa in skin folds
C. A heart rate of 140 beats per minute
D. Nasal flaring and chest retractions
Correct Answer: D
Expert Explanation: Nasal flaring, chest retractions, and grunting are classic signs of
respiratory distress in a newborn. Acrocyanosis is a normal finding in the first 24 to 48
hours of life due to peripheral circulation adjustment. These respiratory distress signs
,require immediate evaluation to ensure the newborn’s airway and oxygenation are
maintained.
4. A nurse is caring for a client who is in the first stage of labor and has an umbilical cord
prolapse. Which of the following is the priority nursing action?
A. Administer oxygen at 10 L/min via nonrebreather mask
B. Apply sterile saline-soaked gauze to the cord
C. Cover the client to maintain thermoregulation
D. Place the client in a Trendelenburg or knee-chest position
Correct Answer: D
Expert Explanation: Umbilical cord prolapse is a medical emergency because the
presenting part compresses the cord, cutting off fetal oxygen. Placing the client in a
Trendelenburg or knee-chest position uses gravity to shift the fetus off the cord. The nurse
should also apply manual upward pressure on the presenting part until a cesarean section
is performed.
5. A nurse is providing discharge teaching to a client who is postpartum and bottle-feeding
her newborn. Which of the following instructions should the nurse include to prevent breast
engorgement?
A. Apply warm compresses to the breasts several times a day
B. Express small amounts of milk manually if breasts feel full
C. Stimulate the nipples during a shower to promote drainage
, D. Wear a tight-fitting supportive bra or breast binder
Correct Answer: D
Expert Explanation: For bottle-feeding mothers, the goal is to suppress lactation and
prevent stimulation. Wearing a tight-fitting bra continuously for the first 72 hours helps
suppress milk production through pressure. The client should also avoid heat and nipple
stimulation, which would otherwise trigger the let-down reflex.
6. A nurse is assessing a client who is at 32 weeks of gestation and reports painless, bright red
vaginal bleeding. Which of the following conditions should the nurse suspect?
A. Abruptio placentae
B. Preterm labor
C. Placenta previa
D. Threatened abortion
Correct Answer: C
Expert Explanation: Placenta previa is characterized by painless, bright red vaginal
bleeding during the second or third trimester. This occurs because the placenta is
implanted over or near the internal cervical os. In contrast, abruptio placentae typically
involves dark red bleeding and significant abdominal pain.
7. A nurse is administering Rho(D) immune globulin to a client. Which of the following clients
should receive this medication?
A. An Rh-negative mother who has an Rh-positive newborn
