PNR 203/PNR203 Exam 2 V1 | Maternal-
Newborn Nursing Q&A with Rationale |
Fortis College
1. A nurse is reviewing a fetal monitor strip and notes late decelerations. Which of the
following is the priority nursing intervention?
A. Place the client in a supine position
B. Increase the oxytocin infusion rate
C. Perform a vaginal examination
D. Reposition the client to a side-lying position
Correct Answer: D
Expert Explanation: Late decelerations are indicative of uteroplacental insufficiency,
which reduces the amount of oxygen reaching the fetus. Repositioning the mother to a side-
lying position improves blood flow to the placenta and is the first step in intrauterine
resuscitation. Other measures include administering oxygen, increasing IV fluids, and
discontinuing oxytocin if it is being infused.
2. Which assessment finding in a client receiving magnesium sulfate for preeclampsia should
the nurse report to the provider immediately?
A. Deep tendon reflexes of 2+
B. Blood pressure of 140/90 mmHg
,C. Urinary output of 40 mL per hour
D. Respiratory rate of 10 breaths per minute
Correct Answer: D
Expert Explanation: A respiratory rate below 12 breaths per minute is a major sign of
magnesium sulfate toxicity and requires immediate intervention. The nurse should stop the
infusion and prepare to administer calcium gluconate, which is the antidote. Other signs of
toxicity include absent deep tendon reflexes and significantly decreased urinary output.
3. A nurse is assessing a newborn 1 minute after birth and finds: heart rate 110,
slow/irregular respirations, some flexion of extremities, grimace when suctioned, and a pink
body with blue extremities. What is the APGAR score?
A. 5
B. 6
C. 7
D. 8
Correct Answer: B
Expert Explanation: The APGAR score is calculated by giving 2 points for heart rate >100,
1 point for slow/irregular respirations, 1 point for some flexion, 1 point for grimace, and 1
point for acrocyanosis. This totals 6 points, which indicates the newborn may require some
resuscitation efforts or close monitoring. Scores between 4 and 6 suggest moderate
distress in the transition to extrauterine life.
, 4. A client in the active phase of labor has her membranes ruptured spontaneously. What is
the nurse’s immediate priority?
A. Document the color and odor of the fluid
B. Assess the fetal heart rate
C. Perform a nitrazine test
D. Change the patient’s underpads
Correct Answer: B
Expert Explanation: The immediate priority after the rupture of membranes is to assess
the fetal heart rate to rule out cord prolapse. A prolapsed cord can lead to fetal distress due
to compression, which would be visible as sudden variable decelerations or bradycardia.
Once fetal well-being is established, the nurse can then document the characteristics of the
amniotic fluid.
5. Which medication is typically administered to a newborn within 1 to 2 hours of birth to
prevent ophthalmia neonatorum?
A. Vitamin K
B. Erythromycin ophthalmic ointment
C. Hepatitis B vaccine
D. Triple Dye
Correct Answer: B
Newborn Nursing Q&A with Rationale |
Fortis College
1. A nurse is reviewing a fetal monitor strip and notes late decelerations. Which of the
following is the priority nursing intervention?
A. Place the client in a supine position
B. Increase the oxytocin infusion rate
C. Perform a vaginal examination
D. Reposition the client to a side-lying position
Correct Answer: D
Expert Explanation: Late decelerations are indicative of uteroplacental insufficiency,
which reduces the amount of oxygen reaching the fetus. Repositioning the mother to a side-
lying position improves blood flow to the placenta and is the first step in intrauterine
resuscitation. Other measures include administering oxygen, increasing IV fluids, and
discontinuing oxytocin if it is being infused.
2. Which assessment finding in a client receiving magnesium sulfate for preeclampsia should
the nurse report to the provider immediately?
A. Deep tendon reflexes of 2+
B. Blood pressure of 140/90 mmHg
,C. Urinary output of 40 mL per hour
D. Respiratory rate of 10 breaths per minute
Correct Answer: D
Expert Explanation: A respiratory rate below 12 breaths per minute is a major sign of
magnesium sulfate toxicity and requires immediate intervention. The nurse should stop the
infusion and prepare to administer calcium gluconate, which is the antidote. Other signs of
toxicity include absent deep tendon reflexes and significantly decreased urinary output.
3. A nurse is assessing a newborn 1 minute after birth and finds: heart rate 110,
slow/irregular respirations, some flexion of extremities, grimace when suctioned, and a pink
body with blue extremities. What is the APGAR score?
A. 5
B. 6
C. 7
D. 8
Correct Answer: B
Expert Explanation: The APGAR score is calculated by giving 2 points for heart rate >100,
1 point for slow/irregular respirations, 1 point for some flexion, 1 point for grimace, and 1
point for acrocyanosis. This totals 6 points, which indicates the newborn may require some
resuscitation efforts or close monitoring. Scores between 4 and 6 suggest moderate
distress in the transition to extrauterine life.
, 4. A client in the active phase of labor has her membranes ruptured spontaneously. What is
the nurse’s immediate priority?
A. Document the color and odor of the fluid
B. Assess the fetal heart rate
C. Perform a nitrazine test
D. Change the patient’s underpads
Correct Answer: B
Expert Explanation: The immediate priority after the rupture of membranes is to assess
the fetal heart rate to rule out cord prolapse. A prolapsed cord can lead to fetal distress due
to compression, which would be visible as sudden variable decelerations or bradycardia.
Once fetal well-being is established, the nurse can then document the characteristics of the
amniotic fluid.
5. Which medication is typically administered to a newborn within 1 to 2 hours of birth to
prevent ophthalmia neonatorum?
A. Vitamin K
B. Erythromycin ophthalmic ointment
C. Hepatitis B vaccine
D. Triple Dye
Correct Answer: B
