NR327/NR 327 Exam 2 V1 | Maternal Child
Nursing Q&A with Rationale | Chamberlain
University
1. A nurse is monitoring a client in the first stage of labor and notes that the fetal heart rate
(FHR) shows late decelerations. Which action should the nurse take first?
A. Change the client’s position to a side-lying position.
B. Increase the rate of the intravenous (IV) infusion.
C. Apply oxygen via a nonrebreather mask at 10 L/min.
D. Notify the healthcare provider immediately.
Correct Answer: A
Rationale: Late decelerations are indicative of uteroplacental insufficiency and require
immediate intervention to improve oxygenation. The first priority is to change the
maternal position to increase blood flow to the placenta and the fetus. While oxygen
administration and notifying the provider are necessary, the initial physical action must be
aimed at relieving the underlying cause of reduced perfusion.
2. A postpartum nurse is assessing a client 2 hours after delivery and finds the fundus to be
boggy and displaced to the right of the midline. What is the most likely cause?
A. Uterine atony
B. Retained placental fragments
,C. Normal involution process
D. Bladder distension
Correct Answer: D
Rationale: A boggy uterus displaced to the right usually indicates a full bladder, which
prevents the uterus from contracting effectively. Distension of the bladder can push the
fundus away from the midline and increase the risk of postpartum hemorrhage. The nurse
should encourage the client to void or catheterize if necessary to allow the uterus to return
to its proper position and tone.
3. The nurse is caring for a newborn immediately after birth. At 1 minute, the newborn has a
heart rate of 110 bpm, 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. 7
C. 6
D. 8
Correct Answer: C
Rationale: The APGAR score is calculated based on five criteria. 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). Totaling these points results in an APGAR score of 6, which indicates the
need for close observation or mild stimulation.
4. A nurse is administering Magnesium Sulfate to a client with severe preeclampsia. Which of
the following findings would indicate toxicity?
A. Respiratory rate of 14 breaths per minute
B. Urine output of 20 mL/hr over the last 4 hours
C. Deep tendon reflexes of 1+
D. Presence of a mild headache
Correct Answer: B
Rationale: Magnesium Sulfate is excreted by the kidneys, and a urine output of less than 30
mL/hr can lead to toxic accumulation of the drug. Signs of toxicity include decreased urine
output, loss of deep tendon reflexes, and respiratory depression. The nurse must monitor
intake and output closely and report low volumes to prevent cardiac or respiratory arrest.
5. A client in labor is receiving an Oxytocin infusion for induction. The nurse notes
contractions are occurring every 2 minutes and lasting 90 seconds. What is the priority
action?
A. Stop the Oxytocin infusion.
B. Continue to monitor the contraction pattern.
C. Prepare for a cesarean section.
Nursing Q&A with Rationale | Chamberlain
University
1. A nurse is monitoring a client in the first stage of labor and notes that the fetal heart rate
(FHR) shows late decelerations. Which action should the nurse take first?
A. Change the client’s position to a side-lying position.
B. Increase the rate of the intravenous (IV) infusion.
C. Apply oxygen via a nonrebreather mask at 10 L/min.
D. Notify the healthcare provider immediately.
Correct Answer: A
Rationale: Late decelerations are indicative of uteroplacental insufficiency and require
immediate intervention to improve oxygenation. The first priority is to change the
maternal position to increase blood flow to the placenta and the fetus. While oxygen
administration and notifying the provider are necessary, the initial physical action must be
aimed at relieving the underlying cause of reduced perfusion.
2. A postpartum nurse is assessing a client 2 hours after delivery and finds the fundus to be
boggy and displaced to the right of the midline. What is the most likely cause?
A. Uterine atony
B. Retained placental fragments
,C. Normal involution process
D. Bladder distension
Correct Answer: D
Rationale: A boggy uterus displaced to the right usually indicates a full bladder, which
prevents the uterus from contracting effectively. Distension of the bladder can push the
fundus away from the midline and increase the risk of postpartum hemorrhage. The nurse
should encourage the client to void or catheterize if necessary to allow the uterus to return
to its proper position and tone.
3. The nurse is caring for a newborn immediately after birth. At 1 minute, the newborn has a
heart rate of 110 bpm, 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. 7
C. 6
D. 8
Correct Answer: C
Rationale: The APGAR score is calculated based on five criteria. 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). Totaling these points results in an APGAR score of 6, which indicates the
need for close observation or mild stimulation.
4. A nurse is administering Magnesium Sulfate to a client with severe preeclampsia. Which of
the following findings would indicate toxicity?
A. Respiratory rate of 14 breaths per minute
B. Urine output of 20 mL/hr over the last 4 hours
C. Deep tendon reflexes of 1+
D. Presence of a mild headache
Correct Answer: B
Rationale: Magnesium Sulfate is excreted by the kidneys, and a urine output of less than 30
mL/hr can lead to toxic accumulation of the drug. Signs of toxicity include decreased urine
output, loss of deep tendon reflexes, and respiratory depression. The nurse must monitor
intake and output closely and report low volumes to prevent cardiac or respiratory arrest.
5. A client in labor is receiving an Oxytocin infusion for induction. The nurse notes
contractions are occurring every 2 minutes and lasting 90 seconds. What is the priority
action?
A. Stop the Oxytocin infusion.
B. Continue to monitor the contraction pattern.
C. Prepare for a cesarean section.
