PNR 203/PNR203 Exam 4 V3 | Maternal-
Newborn Nursing Q&A with Rationale |
Fortis College
1. A nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. Which of
the following findings should the nurse identify as a sign of magnesium toxicity?
A. Blood pressure of 150/90 mmHg
B. Hyperreflexic deep tendon reflexes
C. Increased urinary output
D. Respiratory rate of 10/min
Correct Answer: D
Expert Explanation: Magnesium sulfate is a central nervous system depressant used to
prevent seizures in preeclamptic patients. A respiratory rate below 12 breaths per minute
is a classic sign of toxicity that requires immediate intervention. The nurse should also
monitor for the loss of deep tendon reflexes and decreased urinary output below 30 mL per
hour.
2. A nurse is monitoring a client in labor and notes late decelerations on the fetal heart rate
monitor. Which of the following actions should the nurse take first?
A. Assist the client into a side-lying position
B. Increase the rate of the IV fluid infusion
,C. Administer oxygen via nonrebreather mask
D. Notify the healthcare provider immediately
Correct Answer: A
Expert Explanation: Late decelerations are indicative of uteroplacental insufficiency and
require immediate corrective action. Repositioning the client to a side-lying position is the
priority intervention to improve uterine blood flow. Following repositioning, the nurse
should then apply oxygen, increase IV fluids, and notify the provider.
3. A nurse is assessing a newborn 1 minute after birth and notes a heart rate of 110/min, a
weak cry, some flexion of the extremities, grimacing, and a pink body with blue extremities.
What is the Apgar score?
A. 5
B. 7
C. 6
D. 8
Correct Answer: C
Expert Explanation: The newborn receives 2 points for heart rate (>100), 1 point for
respiratory effort (weak cry), 1 point for muscle tone (some flexion), 1 point for reflex
irritability (grimace), and 1 point for color (acrocyanosis). Adding these together results in
an Apgar score of 6. A score of 6 indicates that the newborn may require some
resuscitation efforts or close observation.
,4. Which of the following medications should the nurse prepare to administer to a newborn
within 1 to 2 hours of birth to prevent ophthalmia neonatorum?
A. Erythromycin ophthalmic ointment
B. Vitamin K (Phytonadione)
C. Hepatitis B vaccine
D. Nystatin suspension
Correct Answer: A
Expert Explanation: Erythromycin ointment is legally required in most jurisdictions to
prevent blindness caused by gonorrhea or chlamydia. It should be applied to the lower
conjunctival sac of each eye shortly after birth. This prophylactic treatment is effective
even if the mother’s infection status is unknown or negative.
5. A nurse is assessing a client who is 2 hours postpartum and finds that the fundus is boggy
and displaced to the right. Which of the following actions should the nurse take?
A. Assist the client to the bathroom to void
B. Perform fundal massage until firm
C. Administer oxytocin as prescribed
D. Notify the provider of a potential hemorrhage
Correct Answer: A
, Expert Explanation: A fundus that is displaced to the right and boggy is a classic sign of
bladder distention. A full bladder prevents the uterus from contracting effectively, which
increases the risk of postpartum hemorrhage. Assisting the client to empty her bladder
should allow the fundus to return to the midline and become firm.
6. A nurse is teaching a newly licensed nurse about the administration of Rho(D) immune
globulin. Which of the following clients should receive this medication?
A. An Rh-negative mother who delivered an Rh-positive infant
B. An Rh-negative mother who delivered an Rh-negative infant
C. An Rh-positive mother who delivered an Rh-negative infant
D. An Rh-positive mother who delivered an Rh-positive infant
Correct Answer: A
Expert Explanation: Rho(D) immune globulin is administered to Rh-negative mothers
who carry or deliver an Rh-positive fetus. This prevents the mother from forming
antibodies that could attack the red blood cells of future Rh-positive fetuses. It is typically
given at 28 weeks of gestation and again within 72 hours after birth if the baby is
confirmed Rh-positive.
7. A nurse is assessing a client at 34 weeks of gestation who reports a sudden onset of bright
red, painless vaginal bleeding. Which of the following conditions should the nurse suspect?
A. Abruptio placentae
B. Preterm labor
Newborn Nursing Q&A with Rationale |
Fortis College
1. A nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. Which of
the following findings should the nurse identify as a sign of magnesium toxicity?
A. Blood pressure of 150/90 mmHg
B. Hyperreflexic deep tendon reflexes
C. Increased urinary output
D. Respiratory rate of 10/min
Correct Answer: D
Expert Explanation: Magnesium sulfate is a central nervous system depressant used to
prevent seizures in preeclamptic patients. A respiratory rate below 12 breaths per minute
is a classic sign of toxicity that requires immediate intervention. The nurse should also
monitor for the loss of deep tendon reflexes and decreased urinary output below 30 mL per
hour.
2. A nurse is monitoring a client in labor and notes late decelerations on the fetal heart rate
monitor. Which of the following actions should the nurse take first?
A. Assist the client into a side-lying position
B. Increase the rate of the IV fluid infusion
,C. Administer oxygen via nonrebreather mask
D. Notify the healthcare provider immediately
Correct Answer: A
Expert Explanation: Late decelerations are indicative of uteroplacental insufficiency and
require immediate corrective action. Repositioning the client to a side-lying position is the
priority intervention to improve uterine blood flow. Following repositioning, the nurse
should then apply oxygen, increase IV fluids, and notify the provider.
3. A nurse is assessing a newborn 1 minute after birth and notes a heart rate of 110/min, a
weak cry, some flexion of the extremities, grimacing, and a pink body with blue extremities.
What is the Apgar score?
A. 5
B. 7
C. 6
D. 8
Correct Answer: C
Expert Explanation: The newborn receives 2 points for heart rate (>100), 1 point for
respiratory effort (weak cry), 1 point for muscle tone (some flexion), 1 point for reflex
irritability (grimace), and 1 point for color (acrocyanosis). Adding these together results in
an Apgar score of 6. A score of 6 indicates that the newborn may require some
resuscitation efforts or close observation.
,4. Which of the following medications should the nurse prepare to administer to a newborn
within 1 to 2 hours of birth to prevent ophthalmia neonatorum?
A. Erythromycin ophthalmic ointment
B. Vitamin K (Phytonadione)
C. Hepatitis B vaccine
D. Nystatin suspension
Correct Answer: A
Expert Explanation: Erythromycin ointment is legally required in most jurisdictions to
prevent blindness caused by gonorrhea or chlamydia. It should be applied to the lower
conjunctival sac of each eye shortly after birth. This prophylactic treatment is effective
even if the mother’s infection status is unknown or negative.
5. A nurse is assessing a client who is 2 hours postpartum and finds that the fundus is boggy
and displaced to the right. Which of the following actions should the nurse take?
A. Assist the client to the bathroom to void
B. Perform fundal massage until firm
C. Administer oxytocin as prescribed
D. Notify the provider of a potential hemorrhage
Correct Answer: A
, Expert Explanation: A fundus that is displaced to the right and boggy is a classic sign of
bladder distention. A full bladder prevents the uterus from contracting effectively, which
increases the risk of postpartum hemorrhage. Assisting the client to empty her bladder
should allow the fundus to return to the midline and become firm.
6. A nurse is teaching a newly licensed nurse about the administration of Rho(D) immune
globulin. Which of the following clients should receive this medication?
A. An Rh-negative mother who delivered an Rh-positive infant
B. An Rh-negative mother who delivered an Rh-negative infant
C. An Rh-positive mother who delivered an Rh-negative infant
D. An Rh-positive mother who delivered an Rh-positive infant
Correct Answer: A
Expert Explanation: Rho(D) immune globulin is administered to Rh-negative mothers
who carry or deliver an Rh-positive fetus. This prevents the mother from forming
antibodies that could attack the red blood cells of future Rh-positive fetuses. It is typically
given at 28 weeks of gestation and again within 72 hours after birth if the baby is
confirmed Rh-positive.
7. A nurse is assessing a client at 34 weeks of gestation who reports a sudden onset of bright
red, painless vaginal bleeding. Which of the following conditions should the nurse suspect?
A. Abruptio placentae
B. Preterm labor
