NUR 202/NUR202 Exam 3 V1 | Maternal-
Newborn Nursing Q&A with Rationale |
Fortis College
1. A nurse is assessing a client who is 12 hours postpartum. The nurse notes the fundus is
firm, 2 cm above the umbilicus, and displaced to the right. Which of the following actions
should the nurse take first?
A. Massage the fundus until it is firm.
B. Administer oxytocin as prescribed.
C. Assist the client to the bathroom to void.
D. Notify the provider of the findings.
Correct Answer: C
Expert Explanation: A displaced fundus to the right and above the umbilicus is a classic
sign of bladder distention. A full bladder prevents the uterus from contracting efficiently,
which increases the risk of postpartum hemorrhage. Assisting the client to empty her
bladder will allow the uterus to return to the midline and descend properly.
2. A nurse is caring for a client in the first stage of labor and notes a fetal heart rate (FHR)
pattern of late decelerations. Which of the following interventions is the priority?
A. Perform a vaginal exam to check for cord prolapse.
B. Increase the rate of maintenance IV fluids.
,C. Apply oxygen at 8 to 10 L/min via nonrebreather mask.
D. Reposition the client into a lateral position.
Correct Answer: D
Expert Explanation: Late decelerations are caused by uteroplacental insufficiency and
require immediate intervention to improve fetal oxygenation. Repositioning the client to a
side-lying position is the first step to alleviate pressure on the vena cava and enhance
placental blood flow. While oxygen and IV fluids are also components of intrauterine
resuscitation, maternal positioning is the initial priority action.
3. Which of the following medications should the nurse anticipate administering to a client at
30 weeks of gestation who is experiencing preterm labor to promote fetal lung maturity?
A. Nifedipine
B. Betamethasone
C. Magnesium sulfate
D. Terbutaline
Correct Answer: B
Expert Explanation: Betamethasone is a corticosteroid administered to mothers in
preterm labor between 24 and 34 weeks of gestation. It stimulates the production of
surfactant in the fetal lungs, reducing the risk of respiratory distress syndrome. The
medication is typically given in two doses, 24 hours apart, for maximum effectiveness.
, 4. A nurse is assessing a newborn 1 minute after birth. The newborn has a heart rate of
110/min, a weak cry, some flexion of the extremities, grimacing when stimulated, and a pink
body with blue extremities. What is the APGAR score?
A. 5
B. 6
C. 7
D. 8
Correct Answer: B
Expert Explanation: The APGAR score calculation is as follows: 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
results together (2+1+1+1+1) yields a total score of 6. This indicates the newborn may
require some resuscitation and close monitoring.
5. A nurse is caring for a client receiving magnesium sulfate for preeclampsia. Which of the
following findings should the nurse report as a sign of magnesium toxicity?
A. Increased urinary output
B. Respiratory rate of 10/min
C. Hyperreflexia (+4 deep tendon reflexes)
D. Blood pressure of 150/95 mmHg
Newborn Nursing Q&A with Rationale |
Fortis College
1. A nurse is assessing a client who is 12 hours postpartum. The nurse notes the fundus is
firm, 2 cm above the umbilicus, and displaced to the right. Which of the following actions
should the nurse take first?
A. Massage the fundus until it is firm.
B. Administer oxytocin as prescribed.
C. Assist the client to the bathroom to void.
D. Notify the provider of the findings.
Correct Answer: C
Expert Explanation: A displaced fundus to the right and above the umbilicus is a classic
sign of bladder distention. A full bladder prevents the uterus from contracting efficiently,
which increases the risk of postpartum hemorrhage. Assisting the client to empty her
bladder will allow the uterus to return to the midline and descend properly.
2. A nurse is caring for a client in the first stage of labor and notes a fetal heart rate (FHR)
pattern of late decelerations. Which of the following interventions is the priority?
A. Perform a vaginal exam to check for cord prolapse.
B. Increase the rate of maintenance IV fluids.
,C. Apply oxygen at 8 to 10 L/min via nonrebreather mask.
D. Reposition the client into a lateral position.
Correct Answer: D
Expert Explanation: Late decelerations are caused by uteroplacental insufficiency and
require immediate intervention to improve fetal oxygenation. Repositioning the client to a
side-lying position is the first step to alleviate pressure on the vena cava and enhance
placental blood flow. While oxygen and IV fluids are also components of intrauterine
resuscitation, maternal positioning is the initial priority action.
3. Which of the following medications should the nurse anticipate administering to a client at
30 weeks of gestation who is experiencing preterm labor to promote fetal lung maturity?
A. Nifedipine
B. Betamethasone
C. Magnesium sulfate
D. Terbutaline
Correct Answer: B
Expert Explanation: Betamethasone is a corticosteroid administered to mothers in
preterm labor between 24 and 34 weeks of gestation. It stimulates the production of
surfactant in the fetal lungs, reducing the risk of respiratory distress syndrome. The
medication is typically given in two doses, 24 hours apart, for maximum effectiveness.
, 4. A nurse is assessing a newborn 1 minute after birth. The newborn has a heart rate of
110/min, a weak cry, some flexion of the extremities, grimacing when stimulated, and a pink
body with blue extremities. What is the APGAR score?
A. 5
B. 6
C. 7
D. 8
Correct Answer: B
Expert Explanation: The APGAR score calculation is as follows: 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
results together (2+1+1+1+1) yields a total score of 6. This indicates the newborn may
require some resuscitation and close monitoring.
5. A nurse is caring for a client receiving magnesium sulfate for preeclampsia. Which of the
following findings should the nurse report as a sign of magnesium toxicity?
A. Increased urinary output
B. Respiratory rate of 10/min
C. Hyperreflexia (+4 deep tendon reflexes)
D. Blood pressure of 150/95 mmHg
