PNR 203/PNR203 Final Exam V1 |
Maternal-Newborn Nursing Q&A with
Rationale | Fortis College
1. A nurse is calculating the estimated date of delivery (EDD) using Naegele’s rule for a client
whose last menstrual period began on September 5th. Which date should the nurse
document?
A. May 12th
B. June 5th
C. June 12th
D. May 28th
Correct Answer: C
Expert Explanation: Naegele’s rule is a standard method used to estimate the delivery
date by calculating from the first day of the last menstrual period. To calculate the EDD, the
nurse adds seven days to the first day of the LMP and then subtracts three months. In this
specific scenario, adding seven days to September 5th results in September 12th, and
subtracting three months results in June 12th.
,2. A client is pregnant for the fourth time. She has one living child born at 39 weeks, twins
born at 34 weeks, and had one miscarriage at 12 weeks. How should the nurse record her
GTPAL?
A. G4, T1, P2, A1, L3
B. G4, T2, P1, A1, L3
C. G4, T1, P1, A1, L3
D. G3, T1, P1, A1, L2
Correct Answer: C
Expert Explanation: The GTPAL system tracks Gravidity (total pregnancies), Term births
(37+ weeks), Preterm births (20-36 weeks), Abortions/miscarriages, and Living children.
This client is currently pregnant (G4), had one term birth (T1), one preterm birth (the
twins count as one pregnancy/event for P but two for L, so P1), one miscarriage (A1), and
has three living children (L3). Accurate documentation of obstetric history is vital for
identifying potential risks in the current pregnancy.
3. Which of the following is considered a positive sign of pregnancy?
A. Positive serum pregnancy test
B. Fetal heart tones heard by Doppler
C. Amenorrhea and morning sickness
D. Chadwick’s sign
,Correct Answer: B
Expert Explanation: Positive signs of pregnancy are those that can only be attributed to
the presence of a fetus. These include hearing fetal heart sounds, visualizing the fetus via
ultrasound, or palpating fetal movement by a trained clinician. Other signs, such as
pregnancy tests or physiological changes like Chadwick’s sign, are categorized as probable
or presumptive because they could be caused by other conditions.
4. A nurse is assessing a client in the first stage of labor and notes the presence of early
decelerations on the fetal heart rate monitor. What is the nurse’s priority action?
A. Administer oxygen via non-rebreather mask
B. Prepare for an emergency cesarean section
C. Turn the client to the left side-lying position
D. Continue to monitor the client
Correct Answer: D
Expert Explanation: Early decelerations are typically caused by fetal head compression
during contractions and are considered a benign finding. They mirror the contraction,
meaning they start and end with the contraction and do not indicate fetal distress.
Therefore, the nurse should continue to monitor the clinical progression of labor without
the need for immediate medical intervention.
, 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. Triple dye
C. Hepatitis B vaccine
D. Erythromycin ophthalmic ointment
Correct Answer: D
Expert Explanation: Erythromycin ointment is applied to the newborn’s eyes as a
prophylactic measure against infections like gonorrhea and chlamydia. These infections
can be transmitted during birth and may lead to blindness if untreated. This procedure is
legally mandated in many regions to ensure neonatal safety and health.
6. A nurse is caring for a client receiving Magnesium Sulfate for preeclampsia. Which
assessment finding should be reported to the provider immediately?
A. Urine output of 20 mL/hr
B. Deep tendon reflexes of 2+
C. Blood pressure of 145/92 mmHg
D. Respiratory rate of 14 breaths/min
Correct Answer: A
Maternal-Newborn Nursing Q&A with
Rationale | Fortis College
1. A nurse is calculating the estimated date of delivery (EDD) using Naegele’s rule for a client
whose last menstrual period began on September 5th. Which date should the nurse
document?
A. May 12th
B. June 5th
C. June 12th
D. May 28th
Correct Answer: C
Expert Explanation: Naegele’s rule is a standard method used to estimate the delivery
date by calculating from the first day of the last menstrual period. To calculate the EDD, the
nurse adds seven days to the first day of the LMP and then subtracts three months. In this
specific scenario, adding seven days to September 5th results in September 12th, and
subtracting three months results in June 12th.
,2. A client is pregnant for the fourth time. She has one living child born at 39 weeks, twins
born at 34 weeks, and had one miscarriage at 12 weeks. How should the nurse record her
GTPAL?
A. G4, T1, P2, A1, L3
B. G4, T2, P1, A1, L3
C. G4, T1, P1, A1, L3
D. G3, T1, P1, A1, L2
Correct Answer: C
Expert Explanation: The GTPAL system tracks Gravidity (total pregnancies), Term births
(37+ weeks), Preterm births (20-36 weeks), Abortions/miscarriages, and Living children.
This client is currently pregnant (G4), had one term birth (T1), one preterm birth (the
twins count as one pregnancy/event for P but two for L, so P1), one miscarriage (A1), and
has three living children (L3). Accurate documentation of obstetric history is vital for
identifying potential risks in the current pregnancy.
3. Which of the following is considered a positive sign of pregnancy?
A. Positive serum pregnancy test
B. Fetal heart tones heard by Doppler
C. Amenorrhea and morning sickness
D. Chadwick’s sign
,Correct Answer: B
Expert Explanation: Positive signs of pregnancy are those that can only be attributed to
the presence of a fetus. These include hearing fetal heart sounds, visualizing the fetus via
ultrasound, or palpating fetal movement by a trained clinician. Other signs, such as
pregnancy tests or physiological changes like Chadwick’s sign, are categorized as probable
or presumptive because they could be caused by other conditions.
4. A nurse is assessing a client in the first stage of labor and notes the presence of early
decelerations on the fetal heart rate monitor. What is the nurse’s priority action?
A. Administer oxygen via non-rebreather mask
B. Prepare for an emergency cesarean section
C. Turn the client to the left side-lying position
D. Continue to monitor the client
Correct Answer: D
Expert Explanation: Early decelerations are typically caused by fetal head compression
during contractions and are considered a benign finding. They mirror the contraction,
meaning they start and end with the contraction and do not indicate fetal distress.
Therefore, the nurse should continue to monitor the clinical progression of labor without
the need for immediate medical intervention.
, 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. Triple dye
C. Hepatitis B vaccine
D. Erythromycin ophthalmic ointment
Correct Answer: D
Expert Explanation: Erythromycin ointment is applied to the newborn’s eyes as a
prophylactic measure against infections like gonorrhea and chlamydia. These infections
can be transmitted during birth and may lead to blindness if untreated. This procedure is
legally mandated in many regions to ensure neonatal safety and health.
6. A nurse is caring for a client receiving Magnesium Sulfate for preeclampsia. Which
assessment finding should be reported to the provider immediately?
A. Urine output of 20 mL/hr
B. Deep tendon reflexes of 2+
C. Blood pressure of 145/92 mmHg
D. Respiratory rate of 14 breaths/min
Correct Answer: A
