PNR 203/PNR203 Exam 3 V2 | Maternal-
Newborn Nursing Q&A with Rationale |
Fortis College
1. A nurse is assessing a client who is 2 hours postpartum and finds the fundus to be boggy
and displaced to the right. Which of the following actions should the nurse take first?
A. Administer oxytocin intravenously
B. Assist the client to the bathroom to void
C. Perform vigorous fundal massage
D. Increase the client’s oral fluid intake
Correct Answer: B
Expert Explanation: A displaced fundus to the right is a classic sign of bladder distention,
which prevents the uterus from contracting effectively. Assisting the client to empty their
bladder will allow the uterus to return to the midline and contract. This intervention is a
priority to prevent postpartum hemorrhage caused by uterine atony.
2. A nurse is caring for a client receiving magnesium sulfate for preeclampsia. Which of the
following findings should the nurse report to the provider as a sign of toxicity?
A. Blood pressure of 140/90 mmHg
B. Respiratory rate of 10/min
C. Urinary output of 40 mL/hr
,D. Presence of 2+ deep tendon reflexes
Correct Answer: B
Expert Explanation: Magnesium sulfate toxicity can cause central nervous system
depression, leading to respiratory depression. A respiratory rate below 12 breaths per
minute is a critical indicator that the infusion must be stopped. The nurse should also
monitor for the loss of deep tendon reflexes and decreased urinary output as signs of
toxicity.
3. Which of the following medications is administered to a newborn within 1 hour of birth to
prevent ophthalmia neonatorum?
A. Erythromycin ophthalmic ointment
B. Vitamin K (Phytonadione)
C. Hepatitis B vaccine
D. Triple dye solution
Correct Answer: A
Expert Explanation: Erythromycin ointment is legally mandated prophylactic treatment
to protect newborns from infections like gonorrhea or chlamydia. These infections can be
acquired during the birth process and lead to blindness if untreated. The nurse should
apply a thin ribbon of ointment to each lower conjunctival sac.
, 4. A newborn has an Apgar score of 7 at 1 minute and 9 at 5 minutes. How should the nurse
interpret these findings?
A. The newborn is in severe distress and needs resuscitation
B. The newborn is experiencing moderate difficulty transitioning
C. The newborn requires immediate admission to the NICU
D. The newborn is adjusting well to extrauterine life
Correct Answer: D
Expert Explanation: Apgar scores between 7 and 10 indicate that the newborn is in stable
condition and adjusting well. The score is calculated based on heart rate, respiratory effort,
muscle tone, reflex irritability, and color. These scores guide the nurse in determining the
immediate need for intervention or routine care.
5. A nurse is educating a postpartum client about lochia flow. Which of the following
descriptions characterizes lochia serosa?
A. Bright red discharge containing small clots
B. Pinkish-brown discharge occurring on days 4 to 10
C. Yellowish-white discharge lasting up to 6 weeks
D. Creamy mucus-like discharge with a foul odor
Correct Answer: B
Newborn Nursing Q&A with Rationale |
Fortis College
1. A nurse is assessing a client who is 2 hours postpartum and finds the fundus to be boggy
and displaced to the right. Which of the following actions should the nurse take first?
A. Administer oxytocin intravenously
B. Assist the client to the bathroom to void
C. Perform vigorous fundal massage
D. Increase the client’s oral fluid intake
Correct Answer: B
Expert Explanation: A displaced fundus to the right is a classic sign of bladder distention,
which prevents the uterus from contracting effectively. Assisting the client to empty their
bladder will allow the uterus to return to the midline and contract. This intervention is a
priority to prevent postpartum hemorrhage caused by uterine atony.
2. A nurse is caring for a client receiving magnesium sulfate for preeclampsia. Which of the
following findings should the nurse report to the provider as a sign of toxicity?
A. Blood pressure of 140/90 mmHg
B. Respiratory rate of 10/min
C. Urinary output of 40 mL/hr
,D. Presence of 2+ deep tendon reflexes
Correct Answer: B
Expert Explanation: Magnesium sulfate toxicity can cause central nervous system
depression, leading to respiratory depression. A respiratory rate below 12 breaths per
minute is a critical indicator that the infusion must be stopped. The nurse should also
monitor for the loss of deep tendon reflexes and decreased urinary output as signs of
toxicity.
3. Which of the following medications is administered to a newborn within 1 hour of birth to
prevent ophthalmia neonatorum?
A. Erythromycin ophthalmic ointment
B. Vitamin K (Phytonadione)
C. Hepatitis B vaccine
D. Triple dye solution
Correct Answer: A
Expert Explanation: Erythromycin ointment is legally mandated prophylactic treatment
to protect newborns from infections like gonorrhea or chlamydia. These infections can be
acquired during the birth process and lead to blindness if untreated. The nurse should
apply a thin ribbon of ointment to each lower conjunctival sac.
, 4. A newborn has an Apgar score of 7 at 1 minute and 9 at 5 minutes. How should the nurse
interpret these findings?
A. The newborn is in severe distress and needs resuscitation
B. The newborn is experiencing moderate difficulty transitioning
C. The newborn requires immediate admission to the NICU
D. The newborn is adjusting well to extrauterine life
Correct Answer: D
Expert Explanation: Apgar scores between 7 and 10 indicate that the newborn is in stable
condition and adjusting well. The score is calculated based on heart rate, respiratory effort,
muscle tone, reflex irritability, and color. These scores guide the nurse in determining the
immediate need for intervention or routine care.
5. A nurse is educating a postpartum client about lochia flow. Which of the following
descriptions characterizes lochia serosa?
A. Bright red discharge containing small clots
B. Pinkish-brown discharge occurring on days 4 to 10
C. Yellowish-white discharge lasting up to 6 weeks
D. Creamy mucus-like discharge with a foul odor
Correct Answer: B
