NUR 202/NUR202 Final Exam V1 | Maternal-
Newborn Nursing Q&A with Rationale | Fortis
College
1. A nurse is calculating the estimated date of delivery (EDD) using Naegele’s rule for a client
whose last menstrual period began on March 10th. What is the correct EDD?
A. December 17th
B. December 3rd
C. January 10th
D. November 17th
Correct Answer: A
Explanation: Naegele’s rule is a standard method used to estimate the due date by adding
one year, subtracting three months, and adding seven days to the first day of the last
menstrual period. For a period starting March 10th, subtracting three months brings us to
December, and adding seven days results in the 17th. This formula assumes a regular 28-
day menstrual cycle and is the most common clinical calculation used in prenatal care.
2. A client at 32 weeks of gestation is receiving magnesium sulfate for the treatment of
preeclampsia. Which of the following findings should the nurse identify as a sign of
magnesium toxicity?
A. Respiratory rate of 10/min
B. Increased urinary output
,C. Hyperreflexic deep tendon reflexes
D. Blood pressure of 150/100 mmHg
Correct Answer: A
Explanation: Magnesium sulfate is a central nervous system depressant, and toxicity is
primarily recognized by a decrease in respiratory rate below 12 breaths per minute. Other
signs of toxicity include the loss of deep tendon reflexes and a significant drop in urinary
output, which can lead to further accumulation of the drug. The nurse must immediately
stop the infusion and notify the provider if these symptoms are observed to prevent
cardiac or respiratory arrest.
3. A nurse is monitoring a fetal heart rate (FHR) tracing and observes late decelerations.
Which of the following actions should the nurse take first?
A. Increase the oxytocin infusion rate
B. Prepare for an immediate vacuum-assisted delivery
C. Assist the client into a side-lying position
D. Perform a vaginal exam to check for cord prolapse
Correct Answer: C
Explanation: Late decelerations are indicative of uteroplacental insufficiency, meaning the
fetus is not receiving adequate oxygen during contractions. Positioning the client on her
side, preferably the left side, relieves pressure on the vena cava and improves blood flow to
,the placenta. This is an essential first-line intervention in intrauterine resuscitation
alongside oxygen administration and increasing IV fluid rates.
4. A nurse is assessing a newborn 1 minute after birth and notes the following: heart rate
110/min, slow/weak cry, some flexion of extremities, grimace when stimulated, and a pink
body with blue extremities. What is the APGAR score?
A. 5
B. 6
C. 7
D. 8
Correct Answer: B
Explanation: The APGAR score is calculated based on five criteria, each worth up to 2
points. In this scenario, the newborn receives 2 points for heart rate (over 100), 1 point for
respiratory effort (slow/weak cry), 1 point for muscle tone (some flexion), 1 point for
reflex irritability (grimace), and 1 point for color (acrocyanosis). A total score of 6 indicates
that the infant may require some assistance with resuscitation or closer monitoring during
the transition period.
5. A nurse is caring for a client who is 2 hours postpartum and has a boggy uterus that is
displaced to the right. Which of the following actions should the nurse take?
A. Administer oxytocin immediately
B. Perform a vigorous fundal massage
, C. Assist the client to the bathroom to void
D. Place the client in a Trendelenburg position
Correct Answer: C
Explanation: A displaced uterus, typically shifted to the right, is a classic sign of bladder
distention in the postpartum period. A full bladder prevents the uterus from contracting
effectively, which significantly increases the risk of postpartum hemorrhage. Assisting the
client to empty her bladder will allow the uterus to return to the midline and firm up,
resolving the ‘bogginess’ in many cases.
6. Which of the following medications is administered to a newborn within 1 to 2 hours of
birth to prevent ophthalmia neonatorum?
A. Vitamin K
B. Erythromycin ophthalmic ointment
C. Hepatitis B vaccine
D. Nystatin suspension
Correct Answer: B
Explanation: Erythromycin ophthalmic ointment is a mandatory prophylactic treatment
used to prevent blindness caused by Neisseria gonorrhoeae or Chlamydia trachomatis
during delivery. Even if the mother’s infection status is unknown or negative, this
medication is standard care to protect the neonate’s vision. The nurse should apply a thin
Newborn Nursing Q&A with Rationale | Fortis
College
1. A nurse is calculating the estimated date of delivery (EDD) using Naegele’s rule for a client
whose last menstrual period began on March 10th. What is the correct EDD?
A. December 17th
B. December 3rd
C. January 10th
D. November 17th
Correct Answer: A
Explanation: Naegele’s rule is a standard method used to estimate the due date by adding
one year, subtracting three months, and adding seven days to the first day of the last
menstrual period. For a period starting March 10th, subtracting three months brings us to
December, and adding seven days results in the 17th. This formula assumes a regular 28-
day menstrual cycle and is the most common clinical calculation used in prenatal care.
2. A client at 32 weeks of gestation is receiving magnesium sulfate for the treatment of
preeclampsia. Which of the following findings should the nurse identify as a sign of
magnesium toxicity?
A. Respiratory rate of 10/min
B. Increased urinary output
,C. Hyperreflexic deep tendon reflexes
D. Blood pressure of 150/100 mmHg
Correct Answer: A
Explanation: Magnesium sulfate is a central nervous system depressant, and toxicity is
primarily recognized by a decrease in respiratory rate below 12 breaths per minute. Other
signs of toxicity include the loss of deep tendon reflexes and a significant drop in urinary
output, which can lead to further accumulation of the drug. The nurse must immediately
stop the infusion and notify the provider if these symptoms are observed to prevent
cardiac or respiratory arrest.
3. A nurse is monitoring a fetal heart rate (FHR) tracing and observes late decelerations.
Which of the following actions should the nurse take first?
A. Increase the oxytocin infusion rate
B. Prepare for an immediate vacuum-assisted delivery
C. Assist the client into a side-lying position
D. Perform a vaginal exam to check for cord prolapse
Correct Answer: C
Explanation: Late decelerations are indicative of uteroplacental insufficiency, meaning the
fetus is not receiving adequate oxygen during contractions. Positioning the client on her
side, preferably the left side, relieves pressure on the vena cava and improves blood flow to
,the placenta. This is an essential first-line intervention in intrauterine resuscitation
alongside oxygen administration and increasing IV fluid rates.
4. A nurse is assessing a newborn 1 minute after birth and notes the following: heart rate
110/min, slow/weak cry, some flexion of extremities, grimace when stimulated, and a pink
body with blue extremities. What is the APGAR score?
A. 5
B. 6
C. 7
D. 8
Correct Answer: B
Explanation: The APGAR score is calculated based on five criteria, each worth up to 2
points. In this scenario, the newborn receives 2 points for heart rate (over 100), 1 point for
respiratory effort (slow/weak cry), 1 point for muscle tone (some flexion), 1 point for
reflex irritability (grimace), and 1 point for color (acrocyanosis). A total score of 6 indicates
that the infant may require some assistance with resuscitation or closer monitoring during
the transition period.
5. A nurse is caring for a client who is 2 hours postpartum and has a boggy uterus that is
displaced to the right. Which of the following actions should the nurse take?
A. Administer oxytocin immediately
B. Perform a vigorous fundal massage
, C. Assist the client to the bathroom to void
D. Place the client in a Trendelenburg position
Correct Answer: C
Explanation: A displaced uterus, typically shifted to the right, is a classic sign of bladder
distention in the postpartum period. A full bladder prevents the uterus from contracting
effectively, which significantly increases the risk of postpartum hemorrhage. Assisting the
client to empty her bladder will allow the uterus to return to the midline and firm up,
resolving the ‘bogginess’ in many cases.
6. Which of the following medications is administered to a newborn within 1 to 2 hours of
birth to prevent ophthalmia neonatorum?
A. Vitamin K
B. Erythromycin ophthalmic ointment
C. Hepatitis B vaccine
D. Nystatin suspension
Correct Answer: B
Explanation: Erythromycin ophthalmic ointment is a mandatory prophylactic treatment
used to prevent blindness caused by Neisseria gonorrhoeae or Chlamydia trachomatis
during delivery. Even if the mother’s infection status is unknown or negative, this
medication is standard care to protect the neonate’s vision. The nurse should apply a thin
