NUR 202/NUR202 Exam 3 V3 | Maternal-Newborn
Nursing Q&A with Rationale | Fortis College
1. A nurse is assessing a client in the first stage of labor and notes a fetal heart rate (FHR)
pattern showing late decelerations. Which action should the nurse prioritize?
A. Increase the infusion rate of oxytocin.
B. Reposition the client into a side-lying position.
C. Instruct the client to begin pushing.
D. Apply a fetal scalp electrode immediately.
Correct Answer: B
Explanation: Late decelerations are indicative of uteroplacental insufficiency, which is a
non-reassuring sign. Repositioning the client to a side-lying position helps improve blood
flow to the placenta and fetus. The nurse should also discontinue oxytocin, administer
oxygen, and increase IV fluids as part of the intrauterine resuscitation protocol.
2. A client at 34 weeks gestation is receiving magnesium sulfate for preeclampsia. The nurse
notes the client’s respiratory rate is 10 breaths/min and deep tendon reflexes are absent.
Which medication should the nurse prepare?
A. Naloxone
B. Terbutaline
C. Calcium gluconate
,D. Sodium bicarbonate
Correct Answer: C
Explanation: Absent deep tendon reflexes and a respiratory rate below 12 breaths/min
are classic signs of magnesium sulfate toxicity. Calcium gluconate is the specific antidote
used to reverse the effects of magnesium overdosage. The nurse must stop the infusion
immediately and notify the healthcare provider to prevent respiratory or cardiac arrest.
3. A nurse is caring for a postpartum client who delivered 2 hours ago. The fundus is boggy
and displaced to the right of the midline. Which action should the nurse take first?
A. Massage the fundus until it is firm.
B. Assist the client to the bathroom to void.
C. Administer methylergonovine intramuscularly.
D. Notify the provider of potential hemorrhage.
Correct Answer: B
Explanation: A fundus that is displaced to the right and is boggy usually indicates a
distended bladder. A full bladder prevents the uterus from contracting efficiently,
increasing the risk of postpartum hemorrhage. Assisting the client to void or catheterizing
them will allow the uterus to return to the midline and contract.
,4. A newborn’s APGAR score at 1 minute is as follows: heart rate 110 bpm, slow/irregular
respiratory effort, some flexion of extremities, grimace during suctioning, and body pink with
blue extremities. What is the assigned score?
A. 5
B. 8
C. 7
D. 6
Correct Answer: D
Explanation: The score is calculated as: Heart rate (2), Respiratory effort (1), Muscle tone
(1), Reflex irritability (1), and Color (1), totaling 6. A score of 6 at one minute indicates the
newborn is having some difficulty adjusting to extrauterine life. This assessment guides the
need for immediate neonatal resuscitation or closer observation.
5. Which clinical finding should the nurse recognize as a characteristic of a placenta previa
rather than an abruptio placentae?
A. Rigid, board-like abdomen
B. Painless, bright red vaginal bleeding
C. Severe abdominal pain
D. Uterine tenderness and hypertonicity
Correct Answer: B
, Explanation: Placenta previa is characterized by painless, bright red bleeding during the
second or third trimester. In contrast, abruptio placentae involves painful bleeding, a rigid
abdomen, and uterine tenderness. Differentiating these conditions is critical because
vaginal examinations are strictly contraindicated in cases of placenta previa.
6. A nurse is teaching a new mother about umbilical cord care. Which instruction is correct?
A. Apply alcohol to the base of the cord three times daily.
B. Pull the cord off gently when it starts to dry.
C. Submerge the baby in a tub of water for cleaning.
D. Keep the diaper folded down below the cord stump.
Correct Answer: D
Explanation: Folding the diaper below the cord stump prevents contamination from urine
and allows the cord to air dry. Current evidence suggests that cleaning with plain water and
keeping the area dry is sufficient to prevent infection. The cord should never be pulled off;
it must fall off naturally, typically within 10 to 14 days.
7. A client in labor is diagnosed with a prolapsed umbilical cord. What is the priority nursing
intervention?
A. Attempt to push the cord back into the uterus.
B. Cover the cord with a dry sterile gauze.
C. Place the client in a knee-chest or Trendelenburg position.
Nursing Q&A with Rationale | Fortis College
1. A nurse is assessing a client in the first stage of labor and notes a fetal heart rate (FHR)
pattern showing late decelerations. Which action should the nurse prioritize?
A. Increase the infusion rate of oxytocin.
B. Reposition the client into a side-lying position.
C. Instruct the client to begin pushing.
D. Apply a fetal scalp electrode immediately.
Correct Answer: B
Explanation: Late decelerations are indicative of uteroplacental insufficiency, which is a
non-reassuring sign. Repositioning the client to a side-lying position helps improve blood
flow to the placenta and fetus. The nurse should also discontinue oxytocin, administer
oxygen, and increase IV fluids as part of the intrauterine resuscitation protocol.
2. A client at 34 weeks gestation is receiving magnesium sulfate for preeclampsia. The nurse
notes the client’s respiratory rate is 10 breaths/min and deep tendon reflexes are absent.
Which medication should the nurse prepare?
A. Naloxone
B. Terbutaline
C. Calcium gluconate
,D. Sodium bicarbonate
Correct Answer: C
Explanation: Absent deep tendon reflexes and a respiratory rate below 12 breaths/min
are classic signs of magnesium sulfate toxicity. Calcium gluconate is the specific antidote
used to reverse the effects of magnesium overdosage. The nurse must stop the infusion
immediately and notify the healthcare provider to prevent respiratory or cardiac arrest.
3. A nurse is caring for a postpartum client who delivered 2 hours ago. The fundus is boggy
and displaced to the right of the midline. Which action should the nurse take first?
A. Massage the fundus until it is firm.
B. Assist the client to the bathroom to void.
C. Administer methylergonovine intramuscularly.
D. Notify the provider of potential hemorrhage.
Correct Answer: B
Explanation: A fundus that is displaced to the right and is boggy usually indicates a
distended bladder. A full bladder prevents the uterus from contracting efficiently,
increasing the risk of postpartum hemorrhage. Assisting the client to void or catheterizing
them will allow the uterus to return to the midline and contract.
,4. A newborn’s APGAR score at 1 minute is as follows: heart rate 110 bpm, slow/irregular
respiratory effort, some flexion of extremities, grimace during suctioning, and body pink with
blue extremities. What is the assigned score?
A. 5
B. 8
C. 7
D. 6
Correct Answer: D
Explanation: The score is calculated as: Heart rate (2), Respiratory effort (1), Muscle tone
(1), Reflex irritability (1), and Color (1), totaling 6. A score of 6 at one minute indicates the
newborn is having some difficulty adjusting to extrauterine life. This assessment guides the
need for immediate neonatal resuscitation or closer observation.
5. Which clinical finding should the nurse recognize as a characteristic of a placenta previa
rather than an abruptio placentae?
A. Rigid, board-like abdomen
B. Painless, bright red vaginal bleeding
C. Severe abdominal pain
D. Uterine tenderness and hypertonicity
Correct Answer: B
, Explanation: Placenta previa is characterized by painless, bright red bleeding during the
second or third trimester. In contrast, abruptio placentae involves painful bleeding, a rigid
abdomen, and uterine tenderness. Differentiating these conditions is critical because
vaginal examinations are strictly contraindicated in cases of placenta previa.
6. A nurse is teaching a new mother about umbilical cord care. Which instruction is correct?
A. Apply alcohol to the base of the cord three times daily.
B. Pull the cord off gently when it starts to dry.
C. Submerge the baby in a tub of water for cleaning.
D. Keep the diaper folded down below the cord stump.
Correct Answer: D
Explanation: Folding the diaper below the cord stump prevents contamination from urine
and allows the cord to air dry. Current evidence suggests that cleaning with plain water and
keeping the area dry is sufficient to prevent infection. The cord should never be pulled off;
it must fall off naturally, typically within 10 to 14 days.
7. A client in labor is diagnosed with a prolapsed umbilical cord. What is the priority nursing
intervention?
A. Attempt to push the cord back into the uterus.
B. Cover the cord with a dry sterile gauze.
C. Place the client in a knee-chest or Trendelenburg position.
