PNR 203/PNR203 Exam 2 V3 | Maternal-
Newborn Nursing Q&A with Rationale |
Fortis College
1. A nurse is assessing a client who is in the third stage of labor. Which of the following
findings should the nurse recognize as a sign of placental separation?
A. A sudden gush of dark blood from the introitus
B. Decrease in the length of the umbilical cord
C. The uterus changes shape from globular to discoid
D. The client reports a sudden decrease in uterine pressure
Correct Answer: A
Expert Explanation: The third stage of labor involves the delivery of the placenta after the
birth of the infant. Signs of placental separation include a sudden gush of dark blood,
lengthening of the umbilical cord, and the uterus changing from a discoid to a globular
shape. The nurse must monitor closely to ensure the placenta is intact and that uterine
contraction begins immediately after delivery.
2. A nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. Which of
the following clinical findings should be reported to the provider as a priority?
A. Urine output of 40 mL/hr
B. Fetal heart rate of 140 beats per minute
,C. Presence of 2+ deep tendon reflexes
D. Respiratory rate of 10 breaths per minute
Correct Answer: D
Expert Explanation: Magnesium sulfate is a central nervous system depressant used to
prevent seizures in preeclamptic patients. A respiratory rate below 12 breaths per minute
is a critical sign of magnesium toxicity and requires immediate intervention. The nurse
should stop the infusion, prepare calcium gluconate as the antidote, and notify the
healthcare provider immediately.
3. A client at 34 weeks of gestation presents with painless, bright red vaginal bleeding. Which
of the following actions should the nurse perform first?
A. Perform a sterile vaginal exam to assess cervical dilation
B. Place the client in a Trendelenburg position
C. Administer oxytocin to control the bleeding
D. Initiate continuous fetal heart rate monitoring
Correct Answer: D
Expert Explanation: Painless, bright red bleeding during the third trimester is a classic
sign of placenta previa. A vaginal examination is strictly contraindicated as it can cause
further placental detachment and life-threatening hemorrhage. The priority is to assess
fetal well-being using external monitoring and evaluate the mother’s hemodynamic status.
,4. A nurse is reviewing the laboratory results of a newborn who is 12 hours old. Which of the
following results should the nurse report to the provider?
A. Hemoglobin 18 g/dL
B. Bilirubin 4 mg/dL
C. Blood glucose 35 mg/dL
D. WBC count 15,000/mm3
Correct Answer: C
Expert Explanation: Hypoglycemia in a newborn is typically defined as a blood glucose
level less than 40 mg/dL. This condition can lead to neurological damage if not treated
promptly with feedings or IV glucose. The nurse should monitor for symptoms such as
jitteriness, lethargy, and poor feeding in newborns with low glucose levels.
5. A nurse is teaching a postpartum client about the use of Rho(D) immune globulin. Which of
the following statements by the client indicates an understanding of the teaching?
A. I will need this medication because my baby is Rh-negative
B. I will only need this medication if I have a cesarean birth
C. This medication will prevent my baby from developing jaundice
D. I should receive this injection within 72 hours of delivery
Correct Answer: D
, Expert Explanation: Rho(D) immune globulin is administered to Rh-negative mothers
who give birth to Rh-positive infants to prevent the formation of antibodies. This injection
must be given within 72 hours of delivery to be effective for future pregnancies. It works by
destroying any fetal Rh-positive blood cells that entered the maternal circulation during
birth.
6. A nurse is assessing a client in the transition phase of the first stage of labor. Which of the
following findings should the nurse expect?
A. The client is talkative and eager to follow instructions
B. Cervical dilation of 3 to 5 cm
C. The client reports a strong urge to push but is only 7 cm dilated
D. Contractions occurring every 2 to 3 minutes lasting 60 to 90 seconds
Correct Answer: D
Expert Explanation: The transition phase is the final part of the first stage of labor,
characterized by cervical dilation from 8 to 10 cm. Contractions during this phase are
intense, frequent (every 2 to 3 minutes), and long-lasting (60 to 90 seconds). The nurse
should provide high-level emotional support and coaching as the client often feels
overwhelmed or loses focus.
7. A nurse is assessing a newborn for developmental dysplasia of the hip (DDH). Which of the
following findings is an indication of this condition?
A. Symmetrical gluteal folds
Newborn Nursing Q&A with Rationale |
Fortis College
1. A nurse is assessing a client who is in the third stage of labor. Which of the following
findings should the nurse recognize as a sign of placental separation?
A. A sudden gush of dark blood from the introitus
B. Decrease in the length of the umbilical cord
C. The uterus changes shape from globular to discoid
D. The client reports a sudden decrease in uterine pressure
Correct Answer: A
Expert Explanation: The third stage of labor involves the delivery of the placenta after the
birth of the infant. Signs of placental separation include a sudden gush of dark blood,
lengthening of the umbilical cord, and the uterus changing from a discoid to a globular
shape. The nurse must monitor closely to ensure the placenta is intact and that uterine
contraction begins immediately after delivery.
2. A nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. Which of
the following clinical findings should be reported to the provider as a priority?
A. Urine output of 40 mL/hr
B. Fetal heart rate of 140 beats per minute
,C. Presence of 2+ deep tendon reflexes
D. Respiratory rate of 10 breaths per minute
Correct Answer: D
Expert Explanation: Magnesium sulfate is a central nervous system depressant used to
prevent seizures in preeclamptic patients. A respiratory rate below 12 breaths per minute
is a critical sign of magnesium toxicity and requires immediate intervention. The nurse
should stop the infusion, prepare calcium gluconate as the antidote, and notify the
healthcare provider immediately.
3. A client at 34 weeks of gestation presents with painless, bright red vaginal bleeding. Which
of the following actions should the nurse perform first?
A. Perform a sterile vaginal exam to assess cervical dilation
B. Place the client in a Trendelenburg position
C. Administer oxytocin to control the bleeding
D. Initiate continuous fetal heart rate monitoring
Correct Answer: D
Expert Explanation: Painless, bright red bleeding during the third trimester is a classic
sign of placenta previa. A vaginal examination is strictly contraindicated as it can cause
further placental detachment and life-threatening hemorrhage. The priority is to assess
fetal well-being using external monitoring and evaluate the mother’s hemodynamic status.
,4. A nurse is reviewing the laboratory results of a newborn who is 12 hours old. Which of the
following results should the nurse report to the provider?
A. Hemoglobin 18 g/dL
B. Bilirubin 4 mg/dL
C. Blood glucose 35 mg/dL
D. WBC count 15,000/mm3
Correct Answer: C
Expert Explanation: Hypoglycemia in a newborn is typically defined as a blood glucose
level less than 40 mg/dL. This condition can lead to neurological damage if not treated
promptly with feedings or IV glucose. The nurse should monitor for symptoms such as
jitteriness, lethargy, and poor feeding in newborns with low glucose levels.
5. A nurse is teaching a postpartum client about the use of Rho(D) immune globulin. Which of
the following statements by the client indicates an understanding of the teaching?
A. I will need this medication because my baby is Rh-negative
B. I will only need this medication if I have a cesarean birth
C. This medication will prevent my baby from developing jaundice
D. I should receive this injection within 72 hours of delivery
Correct Answer: D
, Expert Explanation: Rho(D) immune globulin is administered to Rh-negative mothers
who give birth to Rh-positive infants to prevent the formation of antibodies. This injection
must be given within 72 hours of delivery to be effective for future pregnancies. It works by
destroying any fetal Rh-positive blood cells that entered the maternal circulation during
birth.
6. A nurse is assessing a client in the transition phase of the first stage of labor. Which of the
following findings should the nurse expect?
A. The client is talkative and eager to follow instructions
B. Cervical dilation of 3 to 5 cm
C. The client reports a strong urge to push but is only 7 cm dilated
D. Contractions occurring every 2 to 3 minutes lasting 60 to 90 seconds
Correct Answer: D
Expert Explanation: The transition phase is the final part of the first stage of labor,
characterized by cervical dilation from 8 to 10 cm. Contractions during this phase are
intense, frequent (every 2 to 3 minutes), and long-lasting (60 to 90 seconds). The nurse
should provide high-level emotional support and coaching as the client often feels
overwhelmed or loses focus.
7. A nurse is assessing a newborn for developmental dysplasia of the hip (DDH). Which of the
following findings is an indication of this condition?
A. Symmetrical gluteal folds
