NUR 202/NUR202 Exam 4 V3 | Maternal-
Newborn Nursing Q&A with Rationale |
Fortis College
1. A nurse is assessing a client 2 hours postpartum and finds the fundus is boggy and
displaced to the right of the midline. What is the priority nursing action?
A. Administer a PRN dose of oxytocin.
B. Perform immediate fundal massage.
C. Notify the provider of potential hemorrhage.
D. Assist the client to the bathroom to void.
Correct Answer: D
Expert Explanation: A fundus that is displaced to the right is a classic sign of a distended
bladder. A full bladder prevents the uterus from contracting effectively, which increases the
risk of uterine atony and hemorrhage. Assisting the client to void allows the uterus to
return to the midline and contract properly.
2. Which clinical manifestation should the nurse identify as a potential sign of neonatal
hypoglycemia?
A. Hypertonia and vigorous crying
B. Occasional sneezing
C. Abdominal distention
,D. Jitteriness and lethargy
Correct Answer: D
Expert Explanation: Jitteriness, tremors, and lethargy are common early signs of low
blood glucose levels in a newborn. The brain requires a constant supply of glucose for
metabolism, and deficits often manifest as neurological irritability or depression. Nurses
must monitor infants of diabetic mothers or large-for-gestational-age infants closely for
these symptoms.
3. A nurse is preparing to administer Rho(D) immune globulin to a postpartum client. Which
of the following criteria must be met for this medication to be indicated?
A. The mother is Rh-negative and the infant is Rh-positive.
B. The mother is Rh-negative and the infant is Rh-negative.
C. The mother is Rh-positive and the infant is Rh-negative.
D. The mother is Rh-positive and the infant is Rh-positive.
Correct Answer: A
Expert Explanation: Rho(D) immune globulin is administered to Rh-negative mothers
who give birth to Rh-positive infants to prevent sensitization. This prevents the mother
from forming antibodies that could attack the red blood cells of a future Rh-positive fetus. It
must be administered within 72 hours of delivery to be effective.
, 4. A client is receiving magnesium sulfate for preeclampsia. Which of the following findings
should the nurse report immediately as a sign of toxicity?
A. Urinary output of 40 mL per hour
B. Blood pressure of 140/90 mmHg
C. Report of feeling warm and flushed
D. Absence of patellar deep tendon reflexes
Correct Answer: D
Expert Explanation: The loss of deep tendon reflexes is one of the earliest signs of
magnesium sulfate toxicity. Magnesium acts as a central nervous system depressant, and its
therapeutic range is narrow. Other signs of toxicity include respiratory depression,
extreme lethargy, and cardiac arrest.
5. An infant is born at 39 weeks gestation. At 1 minute, the infant has a heart rate of 110
bpm, a slow/irregular respiratory effort, some flexion of extremities, a grimace when
suctioned, and a completely pink body. What is the APGAR score?
A. 7
B. 6
C. 5
D. 8
Correct Answer: A
Newborn Nursing Q&A with Rationale |
Fortis College
1. A nurse is assessing a client 2 hours postpartum and finds the fundus is boggy and
displaced to the right of the midline. What is the priority nursing action?
A. Administer a PRN dose of oxytocin.
B. Perform immediate fundal massage.
C. Notify the provider of potential hemorrhage.
D. Assist the client to the bathroom to void.
Correct Answer: D
Expert Explanation: A fundus that is displaced to the right is a classic sign of a distended
bladder. A full bladder prevents the uterus from contracting effectively, which increases the
risk of uterine atony and hemorrhage. Assisting the client to void allows the uterus to
return to the midline and contract properly.
2. Which clinical manifestation should the nurse identify as a potential sign of neonatal
hypoglycemia?
A. Hypertonia and vigorous crying
B. Occasional sneezing
C. Abdominal distention
,D. Jitteriness and lethargy
Correct Answer: D
Expert Explanation: Jitteriness, tremors, and lethargy are common early signs of low
blood glucose levels in a newborn. The brain requires a constant supply of glucose for
metabolism, and deficits often manifest as neurological irritability or depression. Nurses
must monitor infants of diabetic mothers or large-for-gestational-age infants closely for
these symptoms.
3. A nurse is preparing to administer Rho(D) immune globulin to a postpartum client. Which
of the following criteria must be met for this medication to be indicated?
A. The mother is Rh-negative and the infant is Rh-positive.
B. The mother is Rh-negative and the infant is Rh-negative.
C. The mother is Rh-positive and the infant is Rh-negative.
D. The mother is Rh-positive and the infant is Rh-positive.
Correct Answer: A
Expert Explanation: Rho(D) immune globulin is administered to Rh-negative mothers
who give birth to Rh-positive infants to prevent sensitization. This prevents the mother
from forming antibodies that could attack the red blood cells of a future Rh-positive fetus. It
must be administered within 72 hours of delivery to be effective.
, 4. A client is receiving magnesium sulfate for preeclampsia. Which of the following findings
should the nurse report immediately as a sign of toxicity?
A. Urinary output of 40 mL per hour
B. Blood pressure of 140/90 mmHg
C. Report of feeling warm and flushed
D. Absence of patellar deep tendon reflexes
Correct Answer: D
Expert Explanation: The loss of deep tendon reflexes is one of the earliest signs of
magnesium sulfate toxicity. Magnesium acts as a central nervous system depressant, and its
therapeutic range is narrow. Other signs of toxicity include respiratory depression,
extreme lethargy, and cardiac arrest.
5. An infant is born at 39 weeks gestation. At 1 minute, the infant has a heart rate of 110
bpm, a slow/irregular respiratory effort, some flexion of extremities, a grimace when
suctioned, and a completely pink body. What is the APGAR score?
A. 7
B. 6
C. 5
D. 8
Correct Answer: A
