PNR 203/PNR203 Exam 2 V2 | Maternal-
Newborn Nursing Q&A with Rationale |
Fortis College
1. A nurse is assessing a pregnant client at 32 weeks of gestation who reports a sudden onset
of bright red, painless vaginal bleeding. Which condition should the nurse suspect?
A. Placenta previa
B. Abruptio placentae
C. Uterine rupture
D. Cervical insufficiency
Correct Answer: A
Expert Explanation: Placenta previa is characterized by the painless onset of bright red
vaginal bleeding in the third trimester as the cervix begins to dilate. In contrast, abruptio
placentae involves painful bleeding and a rigid abdomen. Prompt identification is crucial
for maternal and fetal safety as surgical intervention may be required.
2. Which medication should the nurse anticipate administering to a client in preterm labor at
30 weeks gestation to promote fetal lung maturity?
A. Magnesium sulfate
B. Terbutaline
C. Betamethasone
,D. Indomethacin
Correct Answer: C
Expert Explanation: Betamethasone is a glucocorticoid administered to clients in preterm
labor to stimulate the production of fetal surfactant. This intervention significantly reduces
the risk of respiratory distress syndrome in the newborn. It is typically administered in two
doses 24 hours apart to maximize effectiveness.
3. A nurse is caring for a client receiving magnesium sulfate for preeclampsia. Which finding is
the most concerning and requires immediate intervention?
A. Respiratory rate of 10 breaths per minute
B. Absent deep tendon reflexes
C. Urinary output of 40 mL per hour
D. Serum magnesium level of 6 mEq/L
Correct Answer: A
Expert Explanation: A respiratory rate below 12 breaths per minute is a primary sign of
magnesium sulfate toxicity. While absent deep tendon reflexes also indicate toxicity,
respiratory depression is a life-threatening emergency. The nurse must immediately stop
the infusion and prepare to administer calcium gluconate.
4. A nurse is evaluating a fetal heart rate (FHR) tracing and observes late decelerations. Which
action should the nurse take first?
A. Increase the IV fluid rate
, B. Administer oxygen via nonrebreather mask
C. Document the finding and continue to monitor
D. Change the client’s position to lateral
Correct Answer: D
Expert Explanation: Late decelerations are indicative of uteroplacental insufficiency and
require immediate intrauterine resuscitation. Changing the client’s position to a lateral
side-lying position is the first step to improve blood flow to the placenta. This is followed
by oxygen administration and increasing IV fluids to support maternal blood pressure.
5. A client at 38 weeks gestation is diagnosed with mild preeclampsia. Which instruction
should the nurse include in the home care teaching?
A. Restrict fluid intake to 1 liter per day
B. Maintain a strictly low-protein diet
C. Perform vigorous exercise to improve circulation
D. Report any blurred vision or headaches immediately
Correct Answer: D
Expert Explanation: Blurred vision and headaches are warning signs of worsening
preeclampsia or impending eclampsia due to cerebral edema. Clients must be taught to
monitor for these symptoms and notify their provider instantly. Bed rest or restricted
activity is usually recommended rather than vigorous exercise.
Newborn Nursing Q&A with Rationale |
Fortis College
1. A nurse is assessing a pregnant client at 32 weeks of gestation who reports a sudden onset
of bright red, painless vaginal bleeding. Which condition should the nurse suspect?
A. Placenta previa
B. Abruptio placentae
C. Uterine rupture
D. Cervical insufficiency
Correct Answer: A
Expert Explanation: Placenta previa is characterized by the painless onset of bright red
vaginal bleeding in the third trimester as the cervix begins to dilate. In contrast, abruptio
placentae involves painful bleeding and a rigid abdomen. Prompt identification is crucial
for maternal and fetal safety as surgical intervention may be required.
2. Which medication should the nurse anticipate administering to a client in preterm labor at
30 weeks gestation to promote fetal lung maturity?
A. Magnesium sulfate
B. Terbutaline
C. Betamethasone
,D. Indomethacin
Correct Answer: C
Expert Explanation: Betamethasone is a glucocorticoid administered to clients in preterm
labor to stimulate the production of fetal surfactant. This intervention significantly reduces
the risk of respiratory distress syndrome in the newborn. It is typically administered in two
doses 24 hours apart to maximize effectiveness.
3. A nurse is caring for a client receiving magnesium sulfate for preeclampsia. Which finding is
the most concerning and requires immediate intervention?
A. Respiratory rate of 10 breaths per minute
B. Absent deep tendon reflexes
C. Urinary output of 40 mL per hour
D. Serum magnesium level of 6 mEq/L
Correct Answer: A
Expert Explanation: A respiratory rate below 12 breaths per minute is a primary sign of
magnesium sulfate toxicity. While absent deep tendon reflexes also indicate toxicity,
respiratory depression is a life-threatening emergency. The nurse must immediately stop
the infusion and prepare to administer calcium gluconate.
4. A nurse is evaluating a fetal heart rate (FHR) tracing and observes late decelerations. Which
action should the nurse take first?
A. Increase the IV fluid rate
, B. Administer oxygen via nonrebreather mask
C. Document the finding and continue to monitor
D. Change the client’s position to lateral
Correct Answer: D
Expert Explanation: Late decelerations are indicative of uteroplacental insufficiency and
require immediate intrauterine resuscitation. Changing the client’s position to a lateral
side-lying position is the first step to improve blood flow to the placenta. This is followed
by oxygen administration and increasing IV fluids to support maternal blood pressure.
5. A client at 38 weeks gestation is diagnosed with mild preeclampsia. Which instruction
should the nurse include in the home care teaching?
A. Restrict fluid intake to 1 liter per day
B. Maintain a strictly low-protein diet
C. Perform vigorous exercise to improve circulation
D. Report any blurred vision or headaches immediately
Correct Answer: D
Expert Explanation: Blurred vision and headaches are warning signs of worsening
preeclampsia or impending eclampsia due to cerebral edema. Clients must be taught to
monitor for these symptoms and notify their provider instantly. Bed rest or restricted
activity is usually recommended rather than vigorous exercise.
