NUR 202/NUR202 Exam 2 V3 | Maternal-
Newborn Nursing Q&A with Rationale |
Fortis College
1. A nurse is caring for a client in the active phase of the first stage of labor. The nurse notes
late decelerations on the fetal heart rate monitor. Which action should the nurse take first?
A. Increase the rate of the oxytocin infusion.
B. Document the finding as a normal physiological response.
C. Prepare for an immediate forceps delivery.
D. Assist the client into a lateral position.
Correct Answer: D
Expert Explanation: Late decelerations are indicative of uteroplacental insufficiency and
require immediate intervention to improve oxygenation. Shifting the client to a side-lying
position relieves pressure on the vena cava and improves placental perfusion. The nurse
should also consider administering oxygen and increasing intravenous fluids as part of the
intrauterine resuscitation protocol.
2. A nurse is assessing a postpartum client 2 hours after delivery. The fundus is boggy and
displaced to the right of the midline. Which of the following is the priority nursing action?
A. Administer oxytocin as prescribed.
B. Perform a fundal massage.
,C. Assist the client to the bathroom to void.
D. Notify the provider of a suspected hemorrhage.
Correct Answer: C
Expert Explanation: A fundus that is displaced to the right and boggy typically indicates a
distended bladder, which prevents the uterus from contracting effectively. Assisting the
client to void will allow the uterus to return to the midline and contract properly. If the
fundus remains boggy after voiding, then fundal massage and medication would be
appropriate next steps.
3. A client at 32 weeks gestation is admitted with painless, bright red vaginal bleeding. Which
of the following conditions should the nurse suspect?
A. Abruptio placentae
B. Uterine rupture
C. Preterm labor
D. Placenta previa
Correct Answer: D
Expert Explanation: Placenta previa is characterized by the painless onset of bright red
vaginal bleeding during the second or third trimester. This occurs when the placenta
partially or completely covers the cervical os. In contrast, abruptio placentae typically
involves painful bleeding and a rigid, board-like abdomen.
, 4. A nurse is preparing to administer Rho(D) immune globulin to a client. Which of the
following clients should receive this medication?
A. An Rh-positive mother with an Rh-negative newborn.
B. An Rh-positive mother with an Rh-positive newborn.
C. An Rh-negative mother with an Rh-positive newborn.
D. An Rh-negative mother with an Rh-negative newborn.
Correct Answer: C
Expert Explanation: Rho(D) immune globulin is administered to Rh-negative mothers
who give birth to Rh-positive infants to prevent sensitization. The medication must be
given within 72 hours of delivery to be effective for future pregnancies. This prevents the
mother from developing antibodies that could attack the red blood cells of a subsequent
Rh-positive fetus.
5. A nurse is assessing a newborn 1 minute after birth. The newborn has a heart rate of
110/min, a slow/weak cry, some flexion of the extremities, grimace when stimulated, and a
pink body with blue extremities. What is the Apgar score?
A. 5
B. 7
C. 6
D. 8
Newborn Nursing Q&A with Rationale |
Fortis College
1. A nurse is caring for a client in the active phase of the first stage of labor. The nurse notes
late decelerations on the fetal heart rate monitor. Which action should the nurse take first?
A. Increase the rate of the oxytocin infusion.
B. Document the finding as a normal physiological response.
C. Prepare for an immediate forceps delivery.
D. Assist the client into a lateral position.
Correct Answer: D
Expert Explanation: Late decelerations are indicative of uteroplacental insufficiency and
require immediate intervention to improve oxygenation. Shifting the client to a side-lying
position relieves pressure on the vena cava and improves placental perfusion. The nurse
should also consider administering oxygen and increasing intravenous fluids as part of the
intrauterine resuscitation protocol.
2. A nurse is assessing a postpartum client 2 hours after delivery. The fundus is boggy and
displaced to the right of the midline. Which of the following is the priority nursing action?
A. Administer oxytocin as prescribed.
B. Perform a fundal massage.
,C. Assist the client to the bathroom to void.
D. Notify the provider of a suspected hemorrhage.
Correct Answer: C
Expert Explanation: A fundus that is displaced to the right and boggy typically indicates a
distended bladder, which prevents the uterus from contracting effectively. Assisting the
client to void will allow the uterus to return to the midline and contract properly. If the
fundus remains boggy after voiding, then fundal massage and medication would be
appropriate next steps.
3. A client at 32 weeks gestation is admitted with painless, bright red vaginal bleeding. Which
of the following conditions should the nurse suspect?
A. Abruptio placentae
B. Uterine rupture
C. Preterm labor
D. Placenta previa
Correct Answer: D
Expert Explanation: Placenta previa is characterized by the painless onset of bright red
vaginal bleeding during the second or third trimester. This occurs when the placenta
partially or completely covers the cervical os. In contrast, abruptio placentae typically
involves painful bleeding and a rigid, board-like abdomen.
, 4. A nurse is preparing to administer Rho(D) immune globulin to a client. Which of the
following clients should receive this medication?
A. An Rh-positive mother with an Rh-negative newborn.
B. An Rh-positive mother with an Rh-positive newborn.
C. An Rh-negative mother with an Rh-positive newborn.
D. An Rh-negative mother with an Rh-negative newborn.
Correct Answer: C
Expert Explanation: Rho(D) immune globulin is administered to Rh-negative mothers
who give birth to Rh-positive infants to prevent sensitization. The medication must be
given within 72 hours of delivery to be effective for future pregnancies. This prevents the
mother from developing antibodies that could attack the red blood cells of a subsequent
Rh-positive fetus.
5. A nurse is assessing a newborn 1 minute after birth. The newborn has a heart rate of
110/min, a slow/weak cry, some flexion of the extremities, grimace when stimulated, and a
pink body with blue extremities. What is the Apgar score?
A. 5
B. 7
C. 6
D. 8
