PNR 203/PNR203 Exam 3 V1 | Maternal-
Newborn Nursing Q&A with Rationale |
Fortis College
1. A nurse is assessing a client who is 2 hours postpartum and notes the fundus is displaced to
the right and above the umbilicus. What is the priority nursing action?
A. Perform vigorous fundal massage
B. Assist the client to the bathroom to void
C. Administer oxytocin as prescribed
D. Notify the provider of a suspected hemorrhage
Correct Answer: B
Expert Explanation: A fundus that is displaced to the right and elevated is a classic sign of
bladder distention. A full bladder prevents the uterus from contracting effectively, which
increases the risk of hemorrhage. Assisting the client to void will allow the uterus to return
to the midline and contract properly.
2. A nurse is caring for a client receiving magnesium sulfate for preeclampsia. Which finding
should the nurse report to the provider immediately?
A. Urinary output of 40 mL per hour
B. Deep tendon reflexes of 2+
C. Respiratory rate of 10 breaths per minute
,D. Blood pressure of 150/90 mmHg
Correct Answer: C
Expert Explanation: Magnesium sulfate toxicity can lead to respiratory depression, and a
rate below 12 breaths per minute is a critical finding. The nurse should immediately stop
the infusion and prepare to administer calcium gluconate. Other signs of toxicity include
absent deep tendon reflexes and decreased urinary output below 30 mL/hr.
3. Which characteristic is most indicative of placental abruption rather than placenta previa?
A. Painless, bright red vaginal bleeding
B. A soft, non-tender abdomen
C. Sudden onset of severe abdominal pain
D. Fetal heart rate within normal limits
Correct Answer: C
Expert Explanation: Placental abruption is characterized by painful vaginal bleeding and a
rigid, board-like abdomen due to premature separation of the placenta. In contrast,
placenta previa typically presents with painless, bright red bleeding. Abruption is a medical
emergency that can lead to fetal distress and maternal shock.
4. A newborn is being evaluated 1 minute after birth. The heart rate is 110/min, the cry is
vigorous, there is some flexion of the extremities, the trunk is pink with blue hands and feet,
and the infant sneezes when suctioned. What is the Apgar score?
A. 7
, B. 8
C. 9
D. 10
Correct Answer: B
Expert Explanation: The score is calculated as follows: Heart rate >100 (2), vigorous cry
(2), some flexion/grimace (1), acrocyanosis (1 for pink body/blue extremities), and sneeze
(2 for reflex irritability). This results in a total score of 8. Apgar scores between 7 and 10
are considered normal for a transition to extrauterine life.
5. A postpartum nurse is teaching a new mother about lochia. Which statement by the client
indicates a need for further teaching?
A. Lochia rubra will last for the first 3 days
B. Lochia serosa will be pinkish or brownish in color
C. I should expect lochia rubra to return once I go home
D. If I see a large clot, I should notify my nurse
Correct Answer: C
Expert Explanation: Lochia should progress from rubra (red) to serosa (pink/brown) to
alba (white). A return to lochia rubra after it has changed to serosa or alba can indicate late
postpartum hemorrhage or retained placental fragments. The client needs to be aware that
this regression is abnormal and requires medical assessment.
Newborn Nursing Q&A with Rationale |
Fortis College
1. A nurse is assessing a client who is 2 hours postpartum and notes the fundus is displaced to
the right and above the umbilicus. What is the priority nursing action?
A. Perform vigorous fundal massage
B. Assist the client to the bathroom to void
C. Administer oxytocin as prescribed
D. Notify the provider of a suspected hemorrhage
Correct Answer: B
Expert Explanation: A fundus that is displaced to the right and elevated is a classic sign of
bladder distention. A full bladder prevents the uterus from contracting effectively, which
increases the risk of hemorrhage. Assisting the client to void will allow the uterus to return
to the midline and contract properly.
2. A nurse is caring for a client receiving magnesium sulfate for preeclampsia. Which finding
should the nurse report to the provider immediately?
A. Urinary output of 40 mL per hour
B. Deep tendon reflexes of 2+
C. Respiratory rate of 10 breaths per minute
,D. Blood pressure of 150/90 mmHg
Correct Answer: C
Expert Explanation: Magnesium sulfate toxicity can lead to respiratory depression, and a
rate below 12 breaths per minute is a critical finding. The nurse should immediately stop
the infusion and prepare to administer calcium gluconate. Other signs of toxicity include
absent deep tendon reflexes and decreased urinary output below 30 mL/hr.
3. Which characteristic is most indicative of placental abruption rather than placenta previa?
A. Painless, bright red vaginal bleeding
B. A soft, non-tender abdomen
C. Sudden onset of severe abdominal pain
D. Fetal heart rate within normal limits
Correct Answer: C
Expert Explanation: Placental abruption is characterized by painful vaginal bleeding and a
rigid, board-like abdomen due to premature separation of the placenta. In contrast,
placenta previa typically presents with painless, bright red bleeding. Abruption is a medical
emergency that can lead to fetal distress and maternal shock.
4. A newborn is being evaluated 1 minute after birth. The heart rate is 110/min, the cry is
vigorous, there is some flexion of the extremities, the trunk is pink with blue hands and feet,
and the infant sneezes when suctioned. What is the Apgar score?
A. 7
, B. 8
C. 9
D. 10
Correct Answer: B
Expert Explanation: The score is calculated as follows: Heart rate >100 (2), vigorous cry
(2), some flexion/grimace (1), acrocyanosis (1 for pink body/blue extremities), and sneeze
(2 for reflex irritability). This results in a total score of 8. Apgar scores between 7 and 10
are considered normal for a transition to extrauterine life.
5. A postpartum nurse is teaching a new mother about lochia. Which statement by the client
indicates a need for further teaching?
A. Lochia rubra will last for the first 3 days
B. Lochia serosa will be pinkish or brownish in color
C. I should expect lochia rubra to return once I go home
D. If I see a large clot, I should notify my nurse
Correct Answer: C
Expert Explanation: Lochia should progress from rubra (red) to serosa (pink/brown) to
alba (white). A return to lochia rubra after it has changed to serosa or alba can indicate late
postpartum hemorrhage or retained placental fragments. The client needs to be aware that
this regression is abnormal and requires medical assessment.
