NUR 202/NUR202 Final Exam V1 |
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
nonstress test. Which of the following instructions should the nurse include?
A. You should press the button when you feel the baby move.
B. You will need to lie in a supine position throughout the procedure.
C. You will need to drink a glucose solution 30 minutes before the test.
D. You should remain NPO for 4 hours prior to the test.
Correct Answer: A
Expert Explanation: A nonstress test is used to evaluate fetal well-being by monitoring
fetal heart rate response to movement. The client is instructed to press a button whenever
she feels fetal movement to mark the event on the monitor strip. This allows the nurse to
correlate heart rate accelerations with fetal activity, ensuring a reactive and healthy fetus.
2. A nurse is assessing a client who is 12 hours postpartum and has a fundus that is 2 cm
above the umbilicus and displaced to the right. Which of the following actions should the
nurse take first?
A. Administer oxytocin IV bolus.
B. Notify the provider of a potential hemorrhage.
,C. Massage the fundus until firm.
D. Assist the client to empty her bladder.
Correct Answer: D
Expert Explanation: A displaced and elevated fundus is a classic sign of bladder
distention. A full bladder prevents the uterus from contracting effectively and pushes it
upward and to the side, usually the right. Assisting the client to void is the priority
intervention to allow the uterus to return to its proper position and remain firm.
3. A nurse is providing teaching to a client who is at 30 weeks of gestation and has a new
diagnosis of gestational diabetes mellitus. Which of the following statements by the client
indicates an understanding of the teaching?
A. I will monitor my blood glucose level before each meal and at bedtime.
B. I should avoid exercise because it can cause hypoglycemia.
C. I will limit my carbohydrate intake to 20% of my total calories.
D. I will need to have a cesarean birth because of this diagnosis.
Correct Answer: A
Expert Explanation: Frequent blood glucose monitoring is essential for managing
gestational diabetes and ensuring fetal safety. Monitoring before meals and at bedtime
provides a comprehensive view of how the client’s body is processing glucose throughout
the day. This data helps the healthcare team adjust diet, exercise, or insulin as needed.
,4. A nurse is caring for a newborn who was born at 38 weeks of gestation and weighs 3,200 g
(7.1 lb). Which of the following findings should the nurse report to the provider?
A. Acrocyanosis of the hands and feet
B. A respiratory rate of 50/min
C. Milia on the nose and chin
D. Nasal flaring and grunting
Correct Answer: D
Expert Explanation: Nasal flaring and grunting are signs of respiratory distress in a
newborn and require immediate medical evaluation. While acrocyanosis is a normal
finding in the first 24 to 48 hours, respiratory effort should be quiet and easy. Reporting
these signs promptly ensures that the newborn receives appropriate respiratory support
or intervention.
5. A nurse is teaching a client who is breastfeeding about postpartum nutrition. Which of the
following instructions should the nurse include?
A. Limit your fluid intake to 1 liter per day.
B. Increase your daily caloric intake by 500 calories.
C. Avoid spicy foods to prevent infant colic.
D. Stop taking your prenatal vitamins after discharge.
Correct Answer: B
, Expert Explanation: Breastfeeding mothers require additional energy to support milk
production and meet the nutritional needs of both mother and infant. An increase of
approximately 450 to 500 calories per day is recommended for the first 6 months of
lactation. This ensures the mother maintains her own health while providing high-quality
breast milk.
6. A nurse is preparing to administer magnesium sulfate IV to a client who has severe
preeclampsia. Which of the following items should the nurse have at the bedside?
A. Calcium gluconate
B. Naloxone
C. Protamine sulfate
D. Vitamin K
Correct Answer: A
Expert Explanation: Calcium gluconate is the specific antidote for magnesium sulfate
toxicity. The nurse must have it readily available to reverse respiratory depression or
cardiac arrest if magnesium levels become dangerously high. Frequent monitoring of deep
tendon reflexes and respiratory rate is also mandatory during infusion.
7. A nurse is assessing a client who is in the first stage of labor and has an epidural in place.
The client’s blood pressure is 90/50 mm Hg. Which of the following actions should the nurse
take?
A. Turn the client to a lateral position.
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
nonstress test. Which of the following instructions should the nurse include?
A. You should press the button when you feel the baby move.
B. You will need to lie in a supine position throughout the procedure.
C. You will need to drink a glucose solution 30 minutes before the test.
D. You should remain NPO for 4 hours prior to the test.
Correct Answer: A
Expert Explanation: A nonstress test is used to evaluate fetal well-being by monitoring
fetal heart rate response to movement. The client is instructed to press a button whenever
she feels fetal movement to mark the event on the monitor strip. This allows the nurse to
correlate heart rate accelerations with fetal activity, ensuring a reactive and healthy fetus.
2. A nurse is assessing a client who is 12 hours postpartum and has a fundus that is 2 cm
above the umbilicus and displaced to the right. Which of the following actions should the
nurse take first?
A. Administer oxytocin IV bolus.
B. Notify the provider of a potential hemorrhage.
,C. Massage the fundus until firm.
D. Assist the client to empty her bladder.
Correct Answer: D
Expert Explanation: A displaced and elevated fundus is a classic sign of bladder
distention. A full bladder prevents the uterus from contracting effectively and pushes it
upward and to the side, usually the right. Assisting the client to void is the priority
intervention to allow the uterus to return to its proper position and remain firm.
3. A nurse is providing teaching to a client who is at 30 weeks of gestation and has a new
diagnosis of gestational diabetes mellitus. Which of the following statements by the client
indicates an understanding of the teaching?
A. I will monitor my blood glucose level before each meal and at bedtime.
B. I should avoid exercise because it can cause hypoglycemia.
C. I will limit my carbohydrate intake to 20% of my total calories.
D. I will need to have a cesarean birth because of this diagnosis.
Correct Answer: A
Expert Explanation: Frequent blood glucose monitoring is essential for managing
gestational diabetes and ensuring fetal safety. Monitoring before meals and at bedtime
provides a comprehensive view of how the client’s body is processing glucose throughout
the day. This data helps the healthcare team adjust diet, exercise, or insulin as needed.
,4. A nurse is caring for a newborn who was born at 38 weeks of gestation and weighs 3,200 g
(7.1 lb). Which of the following findings should the nurse report to the provider?
A. Acrocyanosis of the hands and feet
B. A respiratory rate of 50/min
C. Milia on the nose and chin
D. Nasal flaring and grunting
Correct Answer: D
Expert Explanation: Nasal flaring and grunting are signs of respiratory distress in a
newborn and require immediate medical evaluation. While acrocyanosis is a normal
finding in the first 24 to 48 hours, respiratory effort should be quiet and easy. Reporting
these signs promptly ensures that the newborn receives appropriate respiratory support
or intervention.
5. A nurse is teaching a client who is breastfeeding about postpartum nutrition. Which of the
following instructions should the nurse include?
A. Limit your fluid intake to 1 liter per day.
B. Increase your daily caloric intake by 500 calories.
C. Avoid spicy foods to prevent infant colic.
D. Stop taking your prenatal vitamins after discharge.
Correct Answer: B
, Expert Explanation: Breastfeeding mothers require additional energy to support milk
production and meet the nutritional needs of both mother and infant. An increase of
approximately 450 to 500 calories per day is recommended for the first 6 months of
lactation. This ensures the mother maintains her own health while providing high-quality
breast milk.
6. A nurse is preparing to administer magnesium sulfate IV to a client who has severe
preeclampsia. Which of the following items should the nurse have at the bedside?
A. Calcium gluconate
B. Naloxone
C. Protamine sulfate
D. Vitamin K
Correct Answer: A
Expert Explanation: Calcium gluconate is the specific antidote for magnesium sulfate
toxicity. The nurse must have it readily available to reverse respiratory depression or
cardiac arrest if magnesium levels become dangerously high. Frequent monitoring of deep
tendon reflexes and respiratory rate is also mandatory during infusion.
7. A nurse is assessing a client who is in the first stage of labor and has an epidural in place.
The client’s blood pressure is 90/50 mm Hg. Which of the following actions should the nurse
take?
A. Turn the client to a lateral position.
