NUR 202/NUR202 Exam 1 V2 | Maternal-Newborn
Nursing Q&A with Rationale | Fortis College
1. A nurse is calculating the estimated date of delivery (EDD) for a client whose last menstrual
period (LMP) began on March 15. Using Naegele’s rule, what is the expected date of delivery?
A. December 15
B. January 22
C. December 22
D. January 15
Correct Answer: C
Explanation: Naegele’s rule involves subtracting three months and adding seven days to
the first day of the last menstrual period. Starting from March 15, subtracting three months
brings the date to December 15, and adding seven days results in December 22. This
standard calculation assumes a 28-day cycle and is the primary method for dating
pregnancy in a clinical setting.
2. A client at 32 weeks of gestation is diagnosed with gestational hypertension. Which of the
following laboratory findings should the nurse report to the provider as indicative of HELLP
syndrome?
A. Hemoglobin 12 g/dL
B. WBC 10,000/mm³
,C. Creatinine 0.8 mg/dL
D. Platelets 95,000/mm³
Correct Answer: D
Explanation: HELLP syndrome is a severe variant of preeclampsia characterized by
Hemolysis, Elevated Liver enzymes, and Low Platelets. A platelet count below
100,000/mm³ is a diagnostic criterion for the low platelet component of this syndrome.
The nurse must monitor for these changes as they indicate significant multi-organ
involvement and potential risk for hemorrhage.
3. During a routine prenatal visit, a client asks about the ‘feeling of the baby moving.’ The
nurse correctly identifies this presumptive sign of pregnancy as:
A. Lightening
B. Ballottement
C. Chadwick’s sign
D. Quickening
Correct Answer: D
Explanation: Quickening is the maternal perception of fetal movement, usually occurring
between 16 and 20 weeks of gestation. While exciting for the parent, it is considered a
presumptive sign because it is subjective and can be mimicked by gas or peristalsis.
Objective findings like Chadwick’s sign are classified as probable signs, and ultrasound
verification is required for a positive diagnosis.
,4. A nurse is performing Leopold maneuvers on a client at 38 weeks of gestation. What is the
primary purpose of the first maneuver?
A. To determine the fetal attitude
B. To identify the location of the fetal back
C. To assess the descent of the presenting part
D. To determine the fetal part in the fundus
Correct Answer: D
Explanation: The first Leopold maneuver involves palpating the upper abdomen (fundus)
to determine whether the head or breech is present. A head feels hard and round, while the
breech feels softer and irregular. This assessment helps the nurse identify fetal lie and
presentation, which are critical for planning the delivery method.
5. A nurse is monitoring a client in labor and observes late decelerations on the fetal heart
rate (FHR) monitor. Which action should the nurse take first?
A. Reposition the client to a side-lying position
B. Increase the IV fluid rate
C. Perform a vaginal exam
D. Administer oxygen via non-rebreather mask
Correct Answer: A
, Explanation: Late decelerations are indicative of uteroplacental insufficiency and
represent a non-reassuring FHR pattern. The priority intervention is to reposition the
client to the lateral (side-lying) position to improve uterine blood flow and placental
perfusion. Following this, the nurse should increase fluids, administer oxygen, and notify
the healthcare provider if the pattern persists.
6. 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, grimaces when suctioned, and a pink
body with blue extremities. What is the Apgar score?
A. 5
B. 8
C. 7
D. 6
Correct Answer: D
Explanation: The Apgar score is calculated as follows: Heart rate > 100 (2 points), weak
cry (1 point), some flexion (1 point), grimace (1 point), and acrocyanosis (1 point for pink
body/blue limbs). This totals 6 points, indicating the newborn requires some assistance or
closer observation. Clinical judgment is essential in interpreting these scores at the 1 and 5-
minute intervals.
Nursing Q&A with Rationale | Fortis College
1. A nurse is calculating the estimated date of delivery (EDD) for a client whose last menstrual
period (LMP) began on March 15. Using Naegele’s rule, what is the expected date of delivery?
A. December 15
B. January 22
C. December 22
D. January 15
Correct Answer: C
Explanation: Naegele’s rule involves subtracting three months and adding seven days to
the first day of the last menstrual period. Starting from March 15, subtracting three months
brings the date to December 15, and adding seven days results in December 22. This
standard calculation assumes a 28-day cycle and is the primary method for dating
pregnancy in a clinical setting.
2. A client at 32 weeks of gestation is diagnosed with gestational hypertension. Which of the
following laboratory findings should the nurse report to the provider as indicative of HELLP
syndrome?
A. Hemoglobin 12 g/dL
B. WBC 10,000/mm³
,C. Creatinine 0.8 mg/dL
D. Platelets 95,000/mm³
Correct Answer: D
Explanation: HELLP syndrome is a severe variant of preeclampsia characterized by
Hemolysis, Elevated Liver enzymes, and Low Platelets. A platelet count below
100,000/mm³ is a diagnostic criterion for the low platelet component of this syndrome.
The nurse must monitor for these changes as they indicate significant multi-organ
involvement and potential risk for hemorrhage.
3. During a routine prenatal visit, a client asks about the ‘feeling of the baby moving.’ The
nurse correctly identifies this presumptive sign of pregnancy as:
A. Lightening
B. Ballottement
C. Chadwick’s sign
D. Quickening
Correct Answer: D
Explanation: Quickening is the maternal perception of fetal movement, usually occurring
between 16 and 20 weeks of gestation. While exciting for the parent, it is considered a
presumptive sign because it is subjective and can be mimicked by gas or peristalsis.
Objective findings like Chadwick’s sign are classified as probable signs, and ultrasound
verification is required for a positive diagnosis.
,4. A nurse is performing Leopold maneuvers on a client at 38 weeks of gestation. What is the
primary purpose of the first maneuver?
A. To determine the fetal attitude
B. To identify the location of the fetal back
C. To assess the descent of the presenting part
D. To determine the fetal part in the fundus
Correct Answer: D
Explanation: The first Leopold maneuver involves palpating the upper abdomen (fundus)
to determine whether the head or breech is present. A head feels hard and round, while the
breech feels softer and irregular. This assessment helps the nurse identify fetal lie and
presentation, which are critical for planning the delivery method.
5. A nurse is monitoring a client in labor and observes late decelerations on the fetal heart
rate (FHR) monitor. Which action should the nurse take first?
A. Reposition the client to a side-lying position
B. Increase the IV fluid rate
C. Perform a vaginal exam
D. Administer oxygen via non-rebreather mask
Correct Answer: A
, Explanation: Late decelerations are indicative of uteroplacental insufficiency and
represent a non-reassuring FHR pattern. The priority intervention is to reposition the
client to the lateral (side-lying) position to improve uterine blood flow and placental
perfusion. Following this, the nurse should increase fluids, administer oxygen, and notify
the healthcare provider if the pattern persists.
6. 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, grimaces when suctioned, and a pink
body with blue extremities. What is the Apgar score?
A. 5
B. 8
C. 7
D. 6
Correct Answer: D
Explanation: The Apgar score is calculated as follows: Heart rate > 100 (2 points), weak
cry (1 point), some flexion (1 point), grimace (1 point), and acrocyanosis (1 point for pink
body/blue limbs). This totals 6 points, indicating the newborn requires some assistance or
closer observation. Clinical judgment is essential in interpreting these scores at the 1 and 5-
minute intervals.
