PNR 203/PNR203 Exam 3 V3 | Maternal-
Newborn Nursing Q&A with Rationale |
Fortis College
1. A nurse is assessing a postpartum client who is 4 hours post-delivery. The nurse notes the
fundus is firm, 2 cm above the umbilicus, and displaced to the right. What is the priority
nursing action?
A. Massage the fundus immediately.
B. Administer oxytocin as ordered.
C. Assist the client to the bathroom to void.
D. Document the findings as normal.
Correct Answer: C
Expert Explanation: A fundus that is displaced to the right and elevated above the
umbilicus 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 void will allow the uterus to return to the midline and remain firm.
2. A nurse is caring for a newborn immediately after birth. Which of the following APGAR
scores would require immediate intervention and resuscitation?
A. A score of 3 at 1 minute.
B. A score of 7 at 5 minutes.
,C. A score of 9 at 1 minute.
D. A score of 8 at 5 minutes.
Correct Answer: A
Expert Explanation: An APGAR score between 0 and 3 indicates severe distress and
requires immediate resuscitation efforts. Scores of 4 to 6 indicate moderate difficulty, while
7 to 10 are considered normal for a transitioning newborn. The nurse must be prepared
with emergency equipment if the 1-minute score is critically low.
3. A nurse is teaching a client who is pregnant about the purpose of the Rhogam injection.
Which statement by the client indicates an understanding of the teaching?
A. I need this because I have a positive blood type.
B. This shot will protect my baby if I have a different blood type than the father.
C. I only need this shot after I deliver my baby.
D. This medication prevents my body from making antibodies against my baby’s blood.
Correct Answer: D
Expert Explanation: Rho(D) Immune Globulin (Rhogam) is administered to Rh-negative
mothers to prevent sensitization to the Rh factor. It works by preventing the mother’s
immune system from producing antibodies that could attack the red blood cells of an Rh-
positive fetus. This treatment is essential for preventing hemolytic disease of the newborn
in subsequent pregnancies.
, 4. A nurse is monitoring a client who is receiving magnesium sulfate for preeclampsia. Which
finding should the nurse report to the provider as a sign of magnesium toxicity?
A. Respiratory rate of 10/min.
B. Deep tendon reflexes of 2+.
C. Urine output of 40 mL/hr.
D. Blood pressure of 140/90 mmHg.
Correct Answer: A
Expert Explanation: Signs of magnesium sulfate toxicity include a respiratory rate less
than 12/min, loss of deep tendon reflexes, and decreased urinary output. The nurse must
monitor these parameters closely to prevent respiratory or cardiac arrest. If toxicity is
suspected, the infusion must be stopped and calcium gluconate should be administered.
5. A nurse is assessing a newborn 1 hour after birth. Which of the following findings is a
manifestation of respiratory distress?
A. Nasal flaring with each breath.
B. Acrocyanosis of the hands and feet.
C. Respiratory rate of 50/min.
D. Abdominal breathing.
Correct Answer: A
Newborn Nursing Q&A with Rationale |
Fortis College
1. A nurse is assessing a postpartum client who is 4 hours post-delivery. The nurse notes the
fundus is firm, 2 cm above the umbilicus, and displaced to the right. What is the priority
nursing action?
A. Massage the fundus immediately.
B. Administer oxytocin as ordered.
C. Assist the client to the bathroom to void.
D. Document the findings as normal.
Correct Answer: C
Expert Explanation: A fundus that is displaced to the right and elevated above the
umbilicus 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 void will allow the uterus to return to the midline and remain firm.
2. A nurse is caring for a newborn immediately after birth. Which of the following APGAR
scores would require immediate intervention and resuscitation?
A. A score of 3 at 1 minute.
B. A score of 7 at 5 minutes.
,C. A score of 9 at 1 minute.
D. A score of 8 at 5 minutes.
Correct Answer: A
Expert Explanation: An APGAR score between 0 and 3 indicates severe distress and
requires immediate resuscitation efforts. Scores of 4 to 6 indicate moderate difficulty, while
7 to 10 are considered normal for a transitioning newborn. The nurse must be prepared
with emergency equipment if the 1-minute score is critically low.
3. A nurse is teaching a client who is pregnant about the purpose of the Rhogam injection.
Which statement by the client indicates an understanding of the teaching?
A. I need this because I have a positive blood type.
B. This shot will protect my baby if I have a different blood type than the father.
C. I only need this shot after I deliver my baby.
D. This medication prevents my body from making antibodies against my baby’s blood.
Correct Answer: D
Expert Explanation: Rho(D) Immune Globulin (Rhogam) is administered to Rh-negative
mothers to prevent sensitization to the Rh factor. It works by preventing the mother’s
immune system from producing antibodies that could attack the red blood cells of an Rh-
positive fetus. This treatment is essential for preventing hemolytic disease of the newborn
in subsequent pregnancies.
, 4. A nurse is monitoring a client who is receiving magnesium sulfate for preeclampsia. Which
finding should the nurse report to the provider as a sign of magnesium toxicity?
A. Respiratory rate of 10/min.
B. Deep tendon reflexes of 2+.
C. Urine output of 40 mL/hr.
D. Blood pressure of 140/90 mmHg.
Correct Answer: A
Expert Explanation: Signs of magnesium sulfate toxicity include a respiratory rate less
than 12/min, loss of deep tendon reflexes, and decreased urinary output. The nurse must
monitor these parameters closely to prevent respiratory or cardiac arrest. If toxicity is
suspected, the infusion must be stopped and calcium gluconate should be administered.
5. A nurse is assessing a newborn 1 hour after birth. Which of the following findings is a
manifestation of respiratory distress?
A. Nasal flaring with each breath.
B. Acrocyanosis of the hands and feet.
C. Respiratory rate of 50/min.
D. Abdominal breathing.
Correct Answer: A
