PNR 203/PNR203 Final Exam V2 |
Maternal-Newborn Nursing Q&A with
Rationale | Fortis College
1. A nurse is calculating a client’s expected date of delivery using Naegele’s rule. The client’s
last menstrual period began on March 10th. What is the correct date?
A. December 10th
B. December 17th
C. January 17th
D. December 3rd
Correct Answer: B
Expert Explanation: To use Naegele’s rule, the nurse subtracts three months and adds
seven days to the first day of the last menstrual period. Starting from March 10th,
subtracting three months leads to December 10th, and adding seven days results in
December 17th. This calculation assumes a standard 28-day menstrual cycle and is a
primary tool in prenatal care.
2. During a non-stress test (NST), the fetal heart rate accelerates 15 beats/min above baseline
for at least 15 seconds twice in a 20-minute window. How should the nurse document this?
A. Nonreactive
B. Reactive
,C. Negative
D. Positive
Correct Answer: B
Expert Explanation: A reactive non-stress test is characterized by at least two
accelerations of 15 bpm above baseline lasting 15 seconds within a 20-minute period. This
finding indicates fetal well-being and adequate oxygenation through the placenta. If these
criteria are not met within 40 minutes, the test is documented as nonreactive, requiring
further evaluation.
3. A nurse is caring for a client in the first stage of labor who is experiencing late
decelerations on the fetal monitor. Which action is the priority?
A. Assist the client to a side-lying position
B. Perform a vaginal exam to check for cord prolapse
C. Increase the rate of the oxytocin infusion
D. Apply a fetal scalp electrode
Correct Answer: A
Expert Explanation: Late decelerations are indicative of uteroplacental insufficiency,
which reduces oxygen delivery to the fetus. Positioning the client on her side relieves
pressure on the inferior vena cava and improves placental perfusion. The nurse should also
anticipate administering oxygen and increasing intravenous fluids while discontinuing
oxytocin if applicable.
, 4. A client at 34 weeks gestation is receiving magnesium sulfate for preeclampsia. Which
finding should the nurse report immediately?
A. Deep tendon reflexes of 2+
B. Respiratory rate of 14/min
C. Urine output of 20 mL/hr
D. Serum magnesium level of 5 mg/dL
Correct Answer: C
Expert Explanation: Magnesium sulfate is excreted by the kidneys, and a decrease in urine
output below 30 mL/hr can lead to toxic accumulation. Symptoms of magnesium toxicity
include loss of deep tendon reflexes, respiratory depression, and cardiac arrest. The nurse
must monitor output closely to ensure the safety of the client throughout the infusion
process.
5. Which medication is typically administered to a newborn within 1 to 2 hours of birth to
prevent ophthalmia neonatorum?
A. Vitamin K (Phytonadione)
B. Erythromycin Ophthalmic Ointment
C. Hepatitis B Vaccine
D. Gentamicin Ointment
Correct Answer: B
Maternal-Newborn Nursing Q&A with
Rationale | Fortis College
1. A nurse is calculating a client’s expected date of delivery using Naegele’s rule. The client’s
last menstrual period began on March 10th. What is the correct date?
A. December 10th
B. December 17th
C. January 17th
D. December 3rd
Correct Answer: B
Expert Explanation: To use Naegele’s rule, the nurse subtracts three months and adds
seven days to the first day of the last menstrual period. Starting from March 10th,
subtracting three months leads to December 10th, and adding seven days results in
December 17th. This calculation assumes a standard 28-day menstrual cycle and is a
primary tool in prenatal care.
2. During a non-stress test (NST), the fetal heart rate accelerates 15 beats/min above baseline
for at least 15 seconds twice in a 20-minute window. How should the nurse document this?
A. Nonreactive
B. Reactive
,C. Negative
D. Positive
Correct Answer: B
Expert Explanation: A reactive non-stress test is characterized by at least two
accelerations of 15 bpm above baseline lasting 15 seconds within a 20-minute period. This
finding indicates fetal well-being and adequate oxygenation through the placenta. If these
criteria are not met within 40 minutes, the test is documented as nonreactive, requiring
further evaluation.
3. A nurse is caring for a client in the first stage of labor who is experiencing late
decelerations on the fetal monitor. Which action is the priority?
A. Assist the client to a side-lying position
B. Perform a vaginal exam to check for cord prolapse
C. Increase the rate of the oxytocin infusion
D. Apply a fetal scalp electrode
Correct Answer: A
Expert Explanation: Late decelerations are indicative of uteroplacental insufficiency,
which reduces oxygen delivery to the fetus. Positioning the client on her side relieves
pressure on the inferior vena cava and improves placental perfusion. The nurse should also
anticipate administering oxygen and increasing intravenous fluids while discontinuing
oxytocin if applicable.
, 4. A client at 34 weeks gestation is receiving magnesium sulfate for preeclampsia. Which
finding should the nurse report immediately?
A. Deep tendon reflexes of 2+
B. Respiratory rate of 14/min
C. Urine output of 20 mL/hr
D. Serum magnesium level of 5 mg/dL
Correct Answer: C
Expert Explanation: Magnesium sulfate is excreted by the kidneys, and a decrease in urine
output below 30 mL/hr can lead to toxic accumulation. Symptoms of magnesium toxicity
include loss of deep tendon reflexes, respiratory depression, and cardiac arrest. The nurse
must monitor output closely to ensure the safety of the client throughout the infusion
process.
5. Which medication is typically administered to a newborn within 1 to 2 hours of birth to
prevent ophthalmia neonatorum?
A. Vitamin K (Phytonadione)
B. Erythromycin Ophthalmic Ointment
C. Hepatitis B Vaccine
D. Gentamicin Ointment
Correct Answer: B
