NUR 202/NUR202 Final Exam V3 |
Maternal-Newborn Nursing Q&A with
Rationale | Fortis College
1. A nurse is caring for a client who is at 32 weeks of gestation and is receiving magnesium
sulfate IV for preeclampsia. Which of the following findings should the nurse identify as a
priority?
A. Urinary output of 20 mL/hr
B. Respiratory rate of 14/min
C. Absent patellar reflexes
D. Feeling of warmth and flushing
D. Serum magnesium level of 6 mg/dL
Correct Answer: A
Expert Explanation: A urinary output of less than 30 mL/hr is a critical sign of impending
magnesium toxicity because the drug is excreted through the kidneys. While absent
patellar reflexes are also a sign of toxicity, maintaining adequate renal perfusion is the
primary physiological concern to prevent further accumulation. The nurse should
immediately report this finding and prepare the antidote, calcium gluconate.
,2. 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. Heart rate of 140/min while crying
C. Generalized petechiae over the trunk
D. Overlapping cranial sutures
Correct Answer: C
Expert Explanation: Generalized petechiae can indicate a clotting factor deficiency or
infection and require immediate investigation by the provider. In contrast, acrocyanosis is
a normal finding in the first 24 to 48 hours of life due to peripheral circulation adjustment.
Overlapping sutures are a common result of molding during the birthing process and
typically resolve within days.
3. A nurse is caring for a client who is in the active phase of the first stage of labor. The nurse
notes late decelerations on the fetal heart rate monitor. Which of the following actions
should the nurse take first?
A. Increase the IV fluid rate
B. Turn the client onto her side
C. Administer oxygen via nonrebreather mask
D. Perform a vaginal examination
,Correct Answer: B
Expert Explanation: Late decelerations are indicative of uteroplacental insufficiency, and
the first nursing action should be to improve blood flow to the placenta. Turning the client
to a side-lying position relieves pressure on the vena cava and maximizes cardiac output
and placental perfusion. Following this intervention, the nurse should increase fluids and
administer oxygen to further stabilize the fetus.
4. A nurse is teaching a client about the use of Rho(D) immune globulin. Which of the
following information should the nurse include?
A. It is given to Rh-positive mothers who have Rh-negative babies.
B. It is administered at 28 weeks gestation and within 72 hours of delivery if the infant is
Rh-positive.
C. It provides permanent immunity against the Rh factor.
D. It is an oral medication taken daily during the third trimester.
Correct Answer: B
Expert Explanation: Rho(D) immune globulin is administered to Rh-negative mothers to
prevent sensitization to Rh-positive fetal blood. The standard protocol includes a dose at
28 weeks and another after delivery if the newborn is confirmed to be Rh-positive. This
medication must be given for each pregnancy to ensure continued protection for
subsequent fetuses.
, 5. A nurse is assessing a client who is 2 hours postpartum. Which of the following findings is
the priority for the nurse to report?
A. A saturated perineal pad in 15 minutes
B. Lochia rubra with small clots
C. Perineal edema and bruising
D. Fundus is firm and at the level of the umbilicus
Correct Answer: A
Expert Explanation: Saturating a perineal pad in 15 minutes or less is a sign of excessive
bleeding or postpartum hemorrhage and requires immediate intervention. The nurse
should assess the firmness of the fundus and perform fundal massage if it is boggy. This
clinical finding takes precedence over expected findings like localized edema or standard
lochia patterns.
6. A client at 38 weeks gestation reports a sudden gush of clear fluid from the vagina. What is
the priority nursing assessment?
A. Assess the fetal heart rate
B. Check the client’s temperature
C. Perform a Nitrazine test
D. Evaluate the contraction pattern
Correct Answer: A
Maternal-Newborn Nursing Q&A with
Rationale | Fortis College
1. A nurse is caring for a client who is at 32 weeks of gestation and is receiving magnesium
sulfate IV for preeclampsia. Which of the following findings should the nurse identify as a
priority?
A. Urinary output of 20 mL/hr
B. Respiratory rate of 14/min
C. Absent patellar reflexes
D. Feeling of warmth and flushing
D. Serum magnesium level of 6 mg/dL
Correct Answer: A
Expert Explanation: A urinary output of less than 30 mL/hr is a critical sign of impending
magnesium toxicity because the drug is excreted through the kidneys. While absent
patellar reflexes are also a sign of toxicity, maintaining adequate renal perfusion is the
primary physiological concern to prevent further accumulation. The nurse should
immediately report this finding and prepare the antidote, calcium gluconate.
,2. 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. Heart rate of 140/min while crying
C. Generalized petechiae over the trunk
D. Overlapping cranial sutures
Correct Answer: C
Expert Explanation: Generalized petechiae can indicate a clotting factor deficiency or
infection and require immediate investigation by the provider. In contrast, acrocyanosis is
a normal finding in the first 24 to 48 hours of life due to peripheral circulation adjustment.
Overlapping sutures are a common result of molding during the birthing process and
typically resolve within days.
3. A nurse is caring for a client who is in the active phase of the first stage of labor. The nurse
notes late decelerations on the fetal heart rate monitor. Which of the following actions
should the nurse take first?
A. Increase the IV fluid rate
B. Turn the client onto her side
C. Administer oxygen via nonrebreather mask
D. Perform a vaginal examination
,Correct Answer: B
Expert Explanation: Late decelerations are indicative of uteroplacental insufficiency, and
the first nursing action should be to improve blood flow to the placenta. Turning the client
to a side-lying position relieves pressure on the vena cava and maximizes cardiac output
and placental perfusion. Following this intervention, the nurse should increase fluids and
administer oxygen to further stabilize the fetus.
4. A nurse is teaching a client about the use of Rho(D) immune globulin. Which of the
following information should the nurse include?
A. It is given to Rh-positive mothers who have Rh-negative babies.
B. It is administered at 28 weeks gestation and within 72 hours of delivery if the infant is
Rh-positive.
C. It provides permanent immunity against the Rh factor.
D. It is an oral medication taken daily during the third trimester.
Correct Answer: B
Expert Explanation: Rho(D) immune globulin is administered to Rh-negative mothers to
prevent sensitization to Rh-positive fetal blood. The standard protocol includes a dose at
28 weeks and another after delivery if the newborn is confirmed to be Rh-positive. This
medication must be given for each pregnancy to ensure continued protection for
subsequent fetuses.
, 5. A nurse is assessing a client who is 2 hours postpartum. Which of the following findings is
the priority for the nurse to report?
A. A saturated perineal pad in 15 minutes
B. Lochia rubra with small clots
C. Perineal edema and bruising
D. Fundus is firm and at the level of the umbilicus
Correct Answer: A
Expert Explanation: Saturating a perineal pad in 15 minutes or less is a sign of excessive
bleeding or postpartum hemorrhage and requires immediate intervention. The nurse
should assess the firmness of the fundus and perform fundal massage if it is boggy. This
clinical finding takes precedence over expected findings like localized edema or standard
lochia patterns.
6. A client at 38 weeks gestation reports a sudden gush of clear fluid from the vagina. What is
the priority nursing assessment?
A. Assess the fetal heart rate
B. Check the client’s temperature
C. Perform a Nitrazine test
D. Evaluate the contraction pattern
Correct Answer: A
