PNR 203/PNR203 Exam 4 V2 | Maternal-
Newborn Nursing Q&A with Rationale |
Fortis College
1. A nurse is assessing a client 2 hours postpartum and finds the fundus is boggy and
displaced to the right. Which action should the nurse take first?
A. Administer oxytocin as ordered
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 distended
bladder. A full bladder prevents the uterus from contracting effectively, leading to uterine
atony and increased bleeding. Assisting the client to void or catheterizing them will allow
the uterus to return to the midline and contract properly.
2. A patient at 32 weeks gestation is receiving magnesium sulfate for preeclampsia. Which
finding requires the nurse to stop the infusion immediately?
A. Blood pressure of 150/90 mmHg
B. Respiratory rate of 10 breaths per minute
C. Deep tendon reflexes of 2+
,D. Urinary output of 40 mL per hour
Correct Answer: B
Expert Explanation: Magnesium sulfate is a central nervous system depressant, and
respiratory depression below 12 breaths per minute is a primary sign of toxicity. If toxicity
is suspected, the infusion must be stopped to prevent respiratory arrest. The nurse should
also prepare the antidote, calcium gluconate, for administration.
3. When assessing a fetal heart rate (FHR) tracing, the nurse notes early decelerations. What
is the most appropriate nursing intervention?
A. Apply oxygen at 10L via non-rebreather mask
B. Increase the IV fluid rate
C. Turn the client to the left side-lying position
D. Continue to monitor the FHR tracing
Correct Answer: D
Expert Explanation: Early decelerations are caused by fetal head compression during
contractions and are considered a benign finding. They typically mirror the contraction,
starting and ending with it. Because they do not indicate fetal distress, no medical
intervention is required other than continued monitoring.
, 4. A nurse is evaluating an Apgar score for a newborn at 1 minute. The infant has a heart rate
of 110, a slow/irregular respiratory effort, some flexion of extremities, a grimace when
stimulated, and a pink body with blue extremities. What is the score?
A. 5
B. 6
C. 7
D. 8
Correct Answer: B
Expert Explanation: The score is calculated as follows: Heart rate >100 (2 points),
Slow/irregular respirations (1 point), Some flexion (1 point), Grimace (1 point), and
Acrocyanosis (1 point). This totals a score of 6, which indicates the infant may need some
resuscitation efforts like tactile stimulation or oxygen. Apgar scores are performed at 1 and
5 minutes after birth.
5. A nurse is caring for a client in the transition phase of the first stage of labor. Which clinical
manifestation should the nurse expect?
A. The client is irritable and may experience nausea
B. The client reports a strong urge to push
C. The client is talkative and excited
D. The contractions occur every 10 to 15 minutes
Newborn Nursing Q&A with Rationale |
Fortis College
1. A nurse is assessing a client 2 hours postpartum and finds the fundus is boggy and
displaced to the right. Which action should the nurse take first?
A. Administer oxytocin as ordered
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 distended
bladder. A full bladder prevents the uterus from contracting effectively, leading to uterine
atony and increased bleeding. Assisting the client to void or catheterizing them will allow
the uterus to return to the midline and contract properly.
2. A patient at 32 weeks gestation is receiving magnesium sulfate for preeclampsia. Which
finding requires the nurse to stop the infusion immediately?
A. Blood pressure of 150/90 mmHg
B. Respiratory rate of 10 breaths per minute
C. Deep tendon reflexes of 2+
,D. Urinary output of 40 mL per hour
Correct Answer: B
Expert Explanation: Magnesium sulfate is a central nervous system depressant, and
respiratory depression below 12 breaths per minute is a primary sign of toxicity. If toxicity
is suspected, the infusion must be stopped to prevent respiratory arrest. The nurse should
also prepare the antidote, calcium gluconate, for administration.
3. When assessing a fetal heart rate (FHR) tracing, the nurse notes early decelerations. What
is the most appropriate nursing intervention?
A. Apply oxygen at 10L via non-rebreather mask
B. Increase the IV fluid rate
C. Turn the client to the left side-lying position
D. Continue to monitor the FHR tracing
Correct Answer: D
Expert Explanation: Early decelerations are caused by fetal head compression during
contractions and are considered a benign finding. They typically mirror the contraction,
starting and ending with it. Because they do not indicate fetal distress, no medical
intervention is required other than continued monitoring.
, 4. A nurse is evaluating an Apgar score for a newborn at 1 minute. The infant has a heart rate
of 110, a slow/irregular respiratory effort, some flexion of extremities, a grimace when
stimulated, and a pink body with blue extremities. What is the score?
A. 5
B. 6
C. 7
D. 8
Correct Answer: B
Expert Explanation: The score is calculated as follows: Heart rate >100 (2 points),
Slow/irregular respirations (1 point), Some flexion (1 point), Grimace (1 point), and
Acrocyanosis (1 point). This totals a score of 6, which indicates the infant may need some
resuscitation efforts like tactile stimulation or oxygen. Apgar scores are performed at 1 and
5 minutes after birth.
5. A nurse is caring for a client in the transition phase of the first stage of labor. Which clinical
manifestation should the nurse expect?
A. The client is irritable and may experience nausea
B. The client reports a strong urge to push
C. The client is talkative and excited
D. The contractions occur every 10 to 15 minutes
