NUR 202/NUR202 Exam 3 V1 | Maternal-Newborn
Nursing Q&A with Rationale | Fortis College
1. A nurse is monitoring a client receiving Magnesium Sulfate for preeclampsia. Which
assessment finding should the nurse prioritize as a sign of toxicity?
A. Blood pressure of 150/96 mmHg
B. Increased urinary output
C. Absence of deep tendon reflexes
D. Fetal heart rate of 140 bpm
Correct Answer: C
Explanation: The loss of deep tendon reflexes is one of the earliest signs of magnesium
sulfate toxicity. The nurse must also monitor for a respiratory rate below 12 breaths per
minute and decreased urine output. Calcium gluconate should be readily available as the
antidote for magnesium toxicity.
2. Which fetal heart rate pattern indicates to the nurse that the fetus is experiencing cord
compression?
A. Early decelerations
B. Late decelerations
C. Accelerations
D. Variable decelerations
,Correct Answer: D
Explanation: Variable decelerations are typically caused by umbilical cord compression
during labor. These decelerations are characterized by a sudden drop in heart rate with a
rapid return to baseline. Nursing interventions include changing the maternal position and
possibly preparing for an amnioinfusion.
3. A client is in the fourth stage of labor and the nurse notes the fundus is boggy and
displaced to the right. What is the priority nursing action?
A. Perform fundal massage
B. Administer Oxytocin as ordered
C. Notify the provider immediately
D. Encourage the client to void
Correct Answer: D
Explanation: A fundus that is displaced to the right usually indicates a full bladder, which
prevents the uterus from contracting effectively. Encouraging the client to void will allow
the uterus to return to the midline and firm up. If the fundus remains boggy after voiding,
fundal massage should be performed.
4. A nurse is caring for a newborn immediately after birth. Which APGAR component
assessment would be indicated by a heart rate of 90 bpm?
A. Score of 0
B. Score of 1
, C. Score of 2
D. Score of 3
Correct Answer: B
Explanation: In the APGAR scoring system, a heart rate below 100 bpm is assigned a score
of 1. A heart rate above 100 bpm receives a 2, while an absent heart rate receives a 0. This
assessment is critical for determining the neonate’s transition to extrauterine life.
5. A client at 32 weeks gestation is diagnosed with preterm labor. Which medication should
the nurse anticipate administering to promote fetal lung maturity?
A. Terbutaline
B. Magnesium Sulfate
C. Indomethacin
D. Betamethasone
Correct Answer: D
Explanation: Betamethasone is a corticosteroid given to clients in preterm labor to
stimulate the production of surfactant in the fetal lungs. This helps reduce the risk of
respiratory distress syndrome in the newborn. It is typically administered in two doses, 24
hours apart.
6. Which clinical manifestation differentiates Abruptio Placentae from Placenta Previa?
A. Painless, bright red vaginal bleeding
Nursing Q&A with Rationale | Fortis College
1. A nurse is monitoring a client receiving Magnesium Sulfate for preeclampsia. Which
assessment finding should the nurse prioritize as a sign of toxicity?
A. Blood pressure of 150/96 mmHg
B. Increased urinary output
C. Absence of deep tendon reflexes
D. Fetal heart rate of 140 bpm
Correct Answer: C
Explanation: The loss of deep tendon reflexes is one of the earliest signs of magnesium
sulfate toxicity. The nurse must also monitor for a respiratory rate below 12 breaths per
minute and decreased urine output. Calcium gluconate should be readily available as the
antidote for magnesium toxicity.
2. Which fetal heart rate pattern indicates to the nurse that the fetus is experiencing cord
compression?
A. Early decelerations
B. Late decelerations
C. Accelerations
D. Variable decelerations
,Correct Answer: D
Explanation: Variable decelerations are typically caused by umbilical cord compression
during labor. These decelerations are characterized by a sudden drop in heart rate with a
rapid return to baseline. Nursing interventions include changing the maternal position and
possibly preparing for an amnioinfusion.
3. A client is in the fourth stage of labor and the nurse notes the fundus is boggy and
displaced to the right. What is the priority nursing action?
A. Perform fundal massage
B. Administer Oxytocin as ordered
C. Notify the provider immediately
D. Encourage the client to void
Correct Answer: D
Explanation: A fundus that is displaced to the right usually indicates a full bladder, which
prevents the uterus from contracting effectively. Encouraging the client to void will allow
the uterus to return to the midline and firm up. If the fundus remains boggy after voiding,
fundal massage should be performed.
4. A nurse is caring for a newborn immediately after birth. Which APGAR component
assessment would be indicated by a heart rate of 90 bpm?
A. Score of 0
B. Score of 1
, C. Score of 2
D. Score of 3
Correct Answer: B
Explanation: In the APGAR scoring system, a heart rate below 100 bpm is assigned a score
of 1. A heart rate above 100 bpm receives a 2, while an absent heart rate receives a 0. This
assessment is critical for determining the neonate’s transition to extrauterine life.
5. A client at 32 weeks gestation is diagnosed with preterm labor. Which medication should
the nurse anticipate administering to promote fetal lung maturity?
A. Terbutaline
B. Magnesium Sulfate
C. Indomethacin
D. Betamethasone
Correct Answer: D
Explanation: Betamethasone is a corticosteroid given to clients in preterm labor to
stimulate the production of surfactant in the fetal lungs. This helps reduce the risk of
respiratory distress syndrome in the newborn. It is typically administered in two doses, 24
hours apart.
6. Which clinical manifestation differentiates Abruptio Placentae from Placenta Previa?
A. Painless, bright red vaginal bleeding
