NUR 202/NUR202 Final Exam V2 |
Maternal-Newborn Nursing Q&A with
Rationale | Fortis College
1. A nurse is caring for a client who is at 36 weeks of gestation and has a prescription for a
non-stress test (NST). Which of the following results should the nurse identify as a reactive
NST?
A. Fetal heart rate accelerations that occur only during uterine contractions.
B. The presence of at least two fetal heart rate accelerations of 15/min lasting 15 seconds
within a 20-minute period.
C. An average fetal heart rate of 110/min with moderate variability.
D. Absence of fetal heart rate accelerations over a 40-minute period of observation.
Correct Answer: B
Expert Explanation: A reactive non-stress test is a positive sign of fetal well-being,
indicating that the fetal heart rate increases with movement. To meet the criteria, there
must be at least two accelerations that meet the 15 beats per minute for 15 seconds
threshold within a 20-minute window. If these criteria are not met, the test may be
extended or followed up with a biophysical profile to further assess fetal health. This test is
non-invasive and provides a snapshot of how the fetus is responding to its environment.
,2. A nurse is assessing a client who is 2 hours postpartum. The nurse notes that the client’s
fundus is boggy and displaced to the right of the midline. Which of the following actions
should the nurse take first?
A. Perform a vigorous fundal massage.
B. Assist the client to the bathroom to void.
C. Administer oxytocin according to standing orders.
D. Notify the primary healthcare provider immediately.
Correct Answer: B
Expert Explanation: A fundus that is displaced to the right usually indicates a distended
bladder, which prevents the uterus from contracting efficiently. When the bladder is full, it
pushes the uterus out of place, increasing the risk of postpartum hemorrhage. Assisting the
client to void will allow the uterus to return to the midline and firm up naturally. The nurse
should re-evaluate the fundal tone and position after the client has emptied her bladder.
3. A client at 32 weeks of gestation is admitted 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: Placenta previa is characterized by the abnormal implantation of the
placenta near or over the cervical os, leading to painless bleeding. This differs from
abruptio placentae, which typically presents with intense abdominal pain and a rigid,
board-like abdomen. The nurse must avoid performing a vaginal examination on this client
as it could trigger a massive hemorrhage. Management focuses on monitoring fetal well-
being and maternal stability while preparing for a potential cesarean delivery.
4. A nurse is providing discharge teaching to a client who is breastfeeding. Which of the
following statements by the client indicates an understanding of the teaching?
A. I should feed my baby every 4 hours regardless of hunger cues.
B. I should supplement with formula if my baby seems fussy after nursing.
C. I need to wash my nipples with soap and water before each feeding.
D. I will know my baby is getting enough milk if there are 6 to 8 wet diapers a day.
Correct Answer: D
Expert Explanation: Adequate hydration and milk intake in a neonate are best evidenced
by the number of wet diapers, with 6 to 8 being the standard for a well-fed infant after the
first week. Breastfeeding should be demand-based rather than on a strict schedule to
ensure a proper milk supply. Using soap on the nipples can cause drying and cracking, so
only plain water is recommended. Success in breastfeeding is often linked to the mother’s
ability to recognize and respond to the infant’s early hunger cues.
, 5. A nurse is caring for a client in the first stage of labor who has an umbilical cord prolapse.
Which of the following actions is the priority?
A. Apply oxygen via non-rebreather mask at 10 L/min.
B. Increase the rate of the intravenous fluids.
C. Place the client in the knee-chest or Trendelenburg position.
D. Prepare the client for an immediate cesarean birth.
Correct Answer: C
Expert Explanation: In the event of a prolapsed cord, the immediate priority is to relieve
pressure on the cord to prevent fetal hypoxia. Positioning the client in a knee-chest or
Trendelenburg position uses gravity to shift the fetus away from the pelvis. The nurse
should also use a sterile gloved hand to manually lift the presenting part off the cord. Rapid
preparation for surgical intervention is necessary, but maintaining cord perfusion is the
most critical first step.
6. Using Naegele’s rule, what is the estimated date of confinement (EDC) for a client whose
last menstrual period (LMP) began on March 10?
A. November 10
B. December 3
C. January 17
D. December 17
Maternal-Newborn Nursing Q&A with
Rationale | Fortis College
1. A nurse is caring for a client who is at 36 weeks of gestation and has a prescription for a
non-stress test (NST). Which of the following results should the nurse identify as a reactive
NST?
A. Fetal heart rate accelerations that occur only during uterine contractions.
B. The presence of at least two fetal heart rate accelerations of 15/min lasting 15 seconds
within a 20-minute period.
C. An average fetal heart rate of 110/min with moderate variability.
D. Absence of fetal heart rate accelerations over a 40-minute period of observation.
Correct Answer: B
Expert Explanation: A reactive non-stress test is a positive sign of fetal well-being,
indicating that the fetal heart rate increases with movement. To meet the criteria, there
must be at least two accelerations that meet the 15 beats per minute for 15 seconds
threshold within a 20-minute window. If these criteria are not met, the test may be
extended or followed up with a biophysical profile to further assess fetal health. This test is
non-invasive and provides a snapshot of how the fetus is responding to its environment.
,2. A nurse is assessing a client who is 2 hours postpartum. The nurse notes that the client’s
fundus is boggy and displaced to the right of the midline. Which of the following actions
should the nurse take first?
A. Perform a vigorous fundal massage.
B. Assist the client to the bathroom to void.
C. Administer oxytocin according to standing orders.
D. Notify the primary healthcare provider immediately.
Correct Answer: B
Expert Explanation: A fundus that is displaced to the right usually indicates a distended
bladder, which prevents the uterus from contracting efficiently. When the bladder is full, it
pushes the uterus out of place, increasing the risk of postpartum hemorrhage. Assisting the
client to void will allow the uterus to return to the midline and firm up naturally. The nurse
should re-evaluate the fundal tone and position after the client has emptied her bladder.
3. A client at 32 weeks of gestation is admitted 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: Placenta previa is characterized by the abnormal implantation of the
placenta near or over the cervical os, leading to painless bleeding. This differs from
abruptio placentae, which typically presents with intense abdominal pain and a rigid,
board-like abdomen. The nurse must avoid performing a vaginal examination on this client
as it could trigger a massive hemorrhage. Management focuses on monitoring fetal well-
being and maternal stability while preparing for a potential cesarean delivery.
4. A nurse is providing discharge teaching to a client who is breastfeeding. Which of the
following statements by the client indicates an understanding of the teaching?
A. I should feed my baby every 4 hours regardless of hunger cues.
B. I should supplement with formula if my baby seems fussy after nursing.
C. I need to wash my nipples with soap and water before each feeding.
D. I will know my baby is getting enough milk if there are 6 to 8 wet diapers a day.
Correct Answer: D
Expert Explanation: Adequate hydration and milk intake in a neonate are best evidenced
by the number of wet diapers, with 6 to 8 being the standard for a well-fed infant after the
first week. Breastfeeding should be demand-based rather than on a strict schedule to
ensure a proper milk supply. Using soap on the nipples can cause drying and cracking, so
only plain water is recommended. Success in breastfeeding is often linked to the mother’s
ability to recognize and respond to the infant’s early hunger cues.
, 5. A nurse is caring for a client in the first stage of labor who has an umbilical cord prolapse.
Which of the following actions is the priority?
A. Apply oxygen via non-rebreather mask at 10 L/min.
B. Increase the rate of the intravenous fluids.
C. Place the client in the knee-chest or Trendelenburg position.
D. Prepare the client for an immediate cesarean birth.
Correct Answer: C
Expert Explanation: In the event of a prolapsed cord, the immediate priority is to relieve
pressure on the cord to prevent fetal hypoxia. Positioning the client in a knee-chest or
Trendelenburg position uses gravity to shift the fetus away from the pelvis. The nurse
should also use a sterile gloved hand to manually lift the presenting part off the cord. Rapid
preparation for surgical intervention is necessary, but maintaining cord perfusion is the
most critical first step.
6. Using Naegele’s rule, what is the estimated date of confinement (EDC) for a client whose
last menstrual period (LMP) began on March 10?
A. November 10
B. December 3
C. January 17
D. December 17
