PNR 203/PNR203 Exam 4 V1 | Maternal-
Newborn Nursing Q&A with Rationale |
Fortis College
1. A nurse is assessing a newborn at 1 minute after birth and observes the following: heart
rate 110/min, slow/irregular respirations, some flexion of extremities, grimace when
suctioned, and a pink body with blue extremities. What Apgar score should the nurse assign?
A. 5
B. 6
C. 7
D. 8
Correct Answer: B
Expert Explanation: The newborn receives 2 points for heart rate over 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 is having some difficulty
adjusting to extrauterine life. The nurse should continue to monitor and provide necessary
interventions before the 5-minute assessment.
,2. A postpartum nurse is performing a fundal assessment on a client 2 hours after a vaginal
delivery. The nurse finds the fundus is 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 a vigorous fundal massage.
D. Notify the healthcare provider immediately.
Correct Answer: B
Expert Explanation: A fundus that is displaced to the right usually indicates a full bladder,
which prevents the uterus from contracting effectively. Assisting the client to void will
allow the uterus to return to the midline and contract, reducing the risk of hemorrhage.
After the client voids, the nurse should reassess the fundal position and firmness.
3. A nurse is caring for a client who is at 34 weeks gestation and has a prescription for
magnesium sulfate IV to treat preeclampsia. Which of the following findings should the nurse
identify as a sign of magnesium toxicity?
A. Respiratory rate of 10 breaths per minute
B. Hyperreflexia (4+ deep tendon reflexes)
C. Urine output of 40 mL per hour
D. Increased fetal heart rate variability
,Correct Answer: A
Expert Explanation: Magnesium sulfate is a central nervous system depressant used to
prevent seizures in preeclampsia. Toxicity is manifested by respiratory depression (less
than 12/min), loss of deep tendon reflexes, and decreased urinary output. The nurse must
monitor these parameters closely and have calcium gluconate available as the antidote.
4. A nurse is providing discharge teaching to a client who is breastfeeding her newborn.
Which of the following statements by the client indicates an understanding of the teaching?
A. “I should feed my baby on a strict schedule every 4 hours.”
B. “I should wash my nipples with soap and water after every feeding.”
C. “I should offer a bottle of water between feedings if the baby seems thirsty.”
D. “I will know my baby is getting enough milk if he has 6 to 8 wet diapers a day.”
Correct Answer: D
Expert Explanation: Adequate hydration and intake in a breastfed newborn are best
indicated by the number of wet diapers, typically 6 to 8 per day after the first week.
Breastfeeding should be baby-led or on demand rather than a strict schedule. Soap should
be avoided on the nipples as it can cause drying and cracking of the tissue.
5. A nurse is caring for a newborn immediately following birth. Which of the following
medications should the nurse prepare to administer to prevent ophthalmia neonatorum?
A. Vitamin K (Phytonadione)
B. Erythromycin ophthalmic ointment
, C. Hepatitis B vaccine
D. Gentamicin sulfate drops
Correct Answer: B
Expert Explanation: Erythromycin ointment is legally required in most jurisdictions to
prevent neonatal blindness caused by gonorrhea or chlamydia. It is applied to the
conjunctival sac of each eye within 1 to 2 hours of birth. This prophylactic treatment is
effective even if the mother’s infection status is unknown.
6. A nurse is assessing a client who is in the third trimester of pregnancy and reports painless,
bright red vaginal bleeding. The nurse should suspect which of the following conditions?
A. Abruptio placentae
B. Placenta previa
C. Uterine rupture
D. Preterm labor
Correct Answer: B
Expert Explanation: Placenta previa is characterized by the painless onset of bright red
vaginal bleeding as the cervix begins to dilate or efface. This occurs because the placenta is
implanted over or near the internal cervical os. In contrast, abruptio placentae typically
involves painful bleeding and a rigid, board-like abdomen.
Newborn Nursing Q&A with Rationale |
Fortis College
1. A nurse is assessing a newborn at 1 minute after birth and observes the following: heart
rate 110/min, slow/irregular respirations, some flexion of extremities, grimace when
suctioned, and a pink body with blue extremities. What Apgar score should the nurse assign?
A. 5
B. 6
C. 7
D. 8
Correct Answer: B
Expert Explanation: The newborn receives 2 points for heart rate over 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 is having some difficulty
adjusting to extrauterine life. The nurse should continue to monitor and provide necessary
interventions before the 5-minute assessment.
,2. A postpartum nurse is performing a fundal assessment on a client 2 hours after a vaginal
delivery. The nurse finds the fundus is 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 a vigorous fundal massage.
D. Notify the healthcare provider immediately.
Correct Answer: B
Expert Explanation: A fundus that is displaced to the right usually indicates a full bladder,
which prevents the uterus from contracting effectively. Assisting the client to void will
allow the uterus to return to the midline and contract, reducing the risk of hemorrhage.
After the client voids, the nurse should reassess the fundal position and firmness.
3. A nurse is caring for a client who is at 34 weeks gestation and has a prescription for
magnesium sulfate IV to treat preeclampsia. Which of the following findings should the nurse
identify as a sign of magnesium toxicity?
A. Respiratory rate of 10 breaths per minute
B. Hyperreflexia (4+ deep tendon reflexes)
C. Urine output of 40 mL per hour
D. Increased fetal heart rate variability
,Correct Answer: A
Expert Explanation: Magnesium sulfate is a central nervous system depressant used to
prevent seizures in preeclampsia. Toxicity is manifested by respiratory depression (less
than 12/min), loss of deep tendon reflexes, and decreased urinary output. The nurse must
monitor these parameters closely and have calcium gluconate available as the antidote.
4. A nurse is providing discharge teaching to a client who is breastfeeding her newborn.
Which of the following statements by the client indicates an understanding of the teaching?
A. “I should feed my baby on a strict schedule every 4 hours.”
B. “I should wash my nipples with soap and water after every feeding.”
C. “I should offer a bottle of water between feedings if the baby seems thirsty.”
D. “I will know my baby is getting enough milk if he has 6 to 8 wet diapers a day.”
Correct Answer: D
Expert Explanation: Adequate hydration and intake in a breastfed newborn are best
indicated by the number of wet diapers, typically 6 to 8 per day after the first week.
Breastfeeding should be baby-led or on demand rather than a strict schedule. Soap should
be avoided on the nipples as it can cause drying and cracking of the tissue.
5. A nurse is caring for a newborn immediately following birth. Which of the following
medications should the nurse prepare to administer to prevent ophthalmia neonatorum?
A. Vitamin K (Phytonadione)
B. Erythromycin ophthalmic ointment
, C. Hepatitis B vaccine
D. Gentamicin sulfate drops
Correct Answer: B
Expert Explanation: Erythromycin ointment is legally required in most jurisdictions to
prevent neonatal blindness caused by gonorrhea or chlamydia. It is applied to the
conjunctival sac of each eye within 1 to 2 hours of birth. This prophylactic treatment is
effective even if the mother’s infection status is unknown.
6. A nurse is assessing a client who is in the third trimester of pregnancy and reports painless,
bright red vaginal bleeding. The nurse should suspect which of the following conditions?
A. Abruptio placentae
B. Placenta previa
C. Uterine rupture
D. Preterm labor
Correct Answer: B
Expert Explanation: Placenta previa is characterized by the painless onset of bright red
vaginal bleeding as the cervix begins to dilate or efface. This occurs because the placenta is
implanted over or near the internal cervical os. In contrast, abruptio placentae typically
involves painful bleeding and a rigid, board-like abdomen.
