NUR 202/NUR202 Exam 1 V3 | Maternal-Newborn
Nursing Q&A with Rationale | Fortis College
1. A nurse is assessing a client at 12 weeks of gestation. Which of the following findings
should the nurse identify as a presumptive sign of pregnancy?
A. Amenorrhea
B. Chadwick’s sign
C. Positive pregnancy test
D. Hegar’s sign
Correct Answer: A
Explanation: Amenorrhea is a presumptive sign because it is a subjective symptom
reported by the client. Probable signs like Chadwick’s sign and Hegar’s sign are objective
findings observed by an examiner. These signs are often used to identify pregnancy but can
also be caused by factors other than pregnancy.
2. A client’s last menstrual period began on May 10th. Using Naegele’s rule, what is the
estimated date of birth (EDB)?
A. August 17th
B. February 3rd
C. February 17th
D. February 10th
,Correct Answer: C
Explanation: To calculate the EDB using Naegele’s rule, subtract 3 months from the first
day of the last menstrual period and add 7 days. For May 10th, subtracting 3 months gives
February, and adding 7 days to the 10th gives the 17th. This formula assumes a standard
28-day cycle and is the most common method for dating pregnancy.
3. A nurse is reviewing the GTPAL of a client who is pregnant, has a 3-year-old child born at 39
weeks, and had a miscarriage at 10 weeks. How should the nurse document this?
A. G2, T1, P0, A1, L1
B. G3, T1, P0, A1, L1
C. G3, T2, P0, A0, L1
D. G2, T2, P0, A1, L2
Correct Answer: B
Explanation: The client is currently pregnant (G3), has one term birth (T1), zero preterm
births (P0), one abortion/miscarriage (A1), and one living child (L1). The current
pregnancy counts toward Gravidity but not toward parity until delivery. Accurate
documentation of GTPAL is essential for assessing obstetric history and identifying
potential risks.
4. Which of the following interventions is the priority for a nurse when a client is receiving
Magnesium Sulfate for preeclampsia?
A. Assessing respiratory rate every 15 to 60 minutes
, B. Administering calcium gluconate prophylactically
C. Checking deep tendon reflexes every 4 hours
D. Monitoring hourly urine output
Correct Answer: A
Explanation: Magnesium sulfate is a central nervous system depressant used to prevent
seizures in preeclampsia, and respiratory depression is a life-threatening adverse effect.
The nurse must prioritize monitoring the respiratory rate to ensure it remains above 12
breaths per minute. If the respiratory rate drops significantly, the medication must be
discontinued and the provider notified immediately.
5. A nurse is caring for a client in the first stage of labor and notes a fetal heart rate (FHR)
pattern showing early decelerations. Which action should the nurse take?
A. Continue to monitor the FHR pattern
B. Prepare for an immediate cesarean section
C. Administer oxygen via non-rebreather mask
D. Reposition the client to the left side
Correct Answer: A
Explanation: Early decelerations are caused by fetal head compression during
contractions and are considered a benign finding. They typically mirror the contraction and
Nursing Q&A with Rationale | Fortis College
1. A nurse is assessing a client at 12 weeks of gestation. Which of the following findings
should the nurse identify as a presumptive sign of pregnancy?
A. Amenorrhea
B. Chadwick’s sign
C. Positive pregnancy test
D. Hegar’s sign
Correct Answer: A
Explanation: Amenorrhea is a presumptive sign because it is a subjective symptom
reported by the client. Probable signs like Chadwick’s sign and Hegar’s sign are objective
findings observed by an examiner. These signs are often used to identify pregnancy but can
also be caused by factors other than pregnancy.
2. A client’s last menstrual period began on May 10th. Using Naegele’s rule, what is the
estimated date of birth (EDB)?
A. August 17th
B. February 3rd
C. February 17th
D. February 10th
,Correct Answer: C
Explanation: To calculate the EDB using Naegele’s rule, subtract 3 months from the first
day of the last menstrual period and add 7 days. For May 10th, subtracting 3 months gives
February, and adding 7 days to the 10th gives the 17th. This formula assumes a standard
28-day cycle and is the most common method for dating pregnancy.
3. A nurse is reviewing the GTPAL of a client who is pregnant, has a 3-year-old child born at 39
weeks, and had a miscarriage at 10 weeks. How should the nurse document this?
A. G2, T1, P0, A1, L1
B. G3, T1, P0, A1, L1
C. G3, T2, P0, A0, L1
D. G2, T2, P0, A1, L2
Correct Answer: B
Explanation: The client is currently pregnant (G3), has one term birth (T1), zero preterm
births (P0), one abortion/miscarriage (A1), and one living child (L1). The current
pregnancy counts toward Gravidity but not toward parity until delivery. Accurate
documentation of GTPAL is essential for assessing obstetric history and identifying
potential risks.
4. Which of the following interventions is the priority for a nurse when a client is receiving
Magnesium Sulfate for preeclampsia?
A. Assessing respiratory rate every 15 to 60 minutes
, B. Administering calcium gluconate prophylactically
C. Checking deep tendon reflexes every 4 hours
D. Monitoring hourly urine output
Correct Answer: A
Explanation: Magnesium sulfate is a central nervous system depressant used to prevent
seizures in preeclampsia, and respiratory depression is a life-threatening adverse effect.
The nurse must prioritize monitoring the respiratory rate to ensure it remains above 12
breaths per minute. If the respiratory rate drops significantly, the medication must be
discontinued and the provider notified immediately.
5. A nurse is caring for a client in the first stage of labor and notes a fetal heart rate (FHR)
pattern showing early decelerations. Which action should the nurse take?
A. Continue to monitor the FHR pattern
B. Prepare for an immediate cesarean section
C. Administer oxygen via non-rebreather mask
D. Reposition the client to the left side
Correct Answer: A
Explanation: Early decelerations are caused by fetal head compression during
contractions and are considered a benign finding. They typically mirror the contraction and
