NUR 202/NUR202 Final Exam V3 | Maternal-
Newborn Nursing Q&A with Rationale | Fortis
College
1. A nurse is caring for a client who is at 36 weeks of gestation and has a prescription for a
nonstress test (NST). Which of the following instructions should the nurse provide to the
client?
A. You will need to be NPO for 4 hours prior to the test.
B. You will be asked to press a button when you feel the baby move.
C. We will use a medication to stimulate contractions during the test.
D. The test will take approximately 2 hours to complete.
Correct Answer: B
Explanation: A nonstress test is a noninvasive procedure that monitors the fetal heart rate
in response to fetal movement. The client is instructed to press a button whenever she feels
the fetus move to correlate movements with heart rate accelerations. This test is vital for
assessing fetal well-being in high-risk pregnancies or when decreased movement is
reported.
2. A nurse is assessing a client who is in the first stage of labor. The nurse notes that the fetal
heart rate (FHR) shows early decelerations. Which of the following actions should the nurse
take?
A. Document the finding and continue to monitor.
,B. Turn the client to a side-lying position.
C. Administer oxygen via a nonrebreather mask at 10 L/min.
D. Prepare the client for an emergency cesarean birth.
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
do not require medical intervention. The nurse should document the finding as a normal
part of the labor process and continue routine monitoring.
3. A nurse is providing discharge teaching to a client who is 3 days postpartum and
breastfeeding. Which of the following statements by the client indicates an understanding of
the teaching?
A. I should feed my baby every 4 to 5 hours to establish a routine.
B. I will drink about 1 liter of fluid per day while breastfeeding.
C. I should wear a supportive bra to help prevent breast engorgement.
D. I will apply soap to my nipples when I shower to keep them clean.
Correct Answer: C
Explanation: Wearing a well-fitting, supportive bra is recommended to provide comfort
and support the weight of the breasts. To prevent nipple trauma, soap should be avoided
, on the nipples as it can cause drying and cracking. Breastfeeding mothers are encouraged
to feed on demand (usually 8-12 times a day) and increase fluid intake significantly.
4. A nurse is assessing a newborn who was born at 39 weeks of gestation. Which of the
following findings should the nurse report to the provider?
A. A respiratory rate of 50 breaths per minute.
B. Nasal flaring and chest retractions.
C. Blue hands and feet (acrocyanosis).
D. Overlapping of the cranial sutures.
Correct Answer: B
Explanation: Nasal flaring and chest retractions are signs of respiratory distress in a
newborn and require immediate intervention. A normal respiratory rate for a newborn is
30 to 60 per minute. Acrocyanosis and overlapping sutures (molding) are normal findings
in the immediate neonatal period.
5. A nurse is caring for a client who is at 32 weeks of gestation and has preeclampsia. Which
of the following findings is the priority for the nurse to report to the provider?
A. 1+ pitting edema in the lower extremities.
B. Continuous headache that is unresponsive to analgesics.
C. Weight gain of 1 lb (0.45 kg) in one week.
D. Blood pressure of 148/92 mmHg.
Newborn Nursing Q&A with Rationale | Fortis
College
1. A nurse is caring for a client who is at 36 weeks of gestation and has a prescription for a
nonstress test (NST). Which of the following instructions should the nurse provide to the
client?
A. You will need to be NPO for 4 hours prior to the test.
B. You will be asked to press a button when you feel the baby move.
C. We will use a medication to stimulate contractions during the test.
D. The test will take approximately 2 hours to complete.
Correct Answer: B
Explanation: A nonstress test is a noninvasive procedure that monitors the fetal heart rate
in response to fetal movement. The client is instructed to press a button whenever she feels
the fetus move to correlate movements with heart rate accelerations. This test is vital for
assessing fetal well-being in high-risk pregnancies or when decreased movement is
reported.
2. A nurse is assessing a client who is in the first stage of labor. The nurse notes that the fetal
heart rate (FHR) shows early decelerations. Which of the following actions should the nurse
take?
A. Document the finding and continue to monitor.
,B. Turn the client to a side-lying position.
C. Administer oxygen via a nonrebreather mask at 10 L/min.
D. Prepare the client for an emergency cesarean birth.
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
do not require medical intervention. The nurse should document the finding as a normal
part of the labor process and continue routine monitoring.
3. A nurse is providing discharge teaching to a client who is 3 days postpartum and
breastfeeding. Which of the following statements by the client indicates an understanding of
the teaching?
A. I should feed my baby every 4 to 5 hours to establish a routine.
B. I will drink about 1 liter of fluid per day while breastfeeding.
C. I should wear a supportive bra to help prevent breast engorgement.
D. I will apply soap to my nipples when I shower to keep them clean.
Correct Answer: C
Explanation: Wearing a well-fitting, supportive bra is recommended to provide comfort
and support the weight of the breasts. To prevent nipple trauma, soap should be avoided
, on the nipples as it can cause drying and cracking. Breastfeeding mothers are encouraged
to feed on demand (usually 8-12 times a day) and increase fluid intake significantly.
4. A nurse is assessing a newborn who was born at 39 weeks of gestation. Which of the
following findings should the nurse report to the provider?
A. A respiratory rate of 50 breaths per minute.
B. Nasal flaring and chest retractions.
C. Blue hands and feet (acrocyanosis).
D. Overlapping of the cranial sutures.
Correct Answer: B
Explanation: Nasal flaring and chest retractions are signs of respiratory distress in a
newborn and require immediate intervention. A normal respiratory rate for a newborn is
30 to 60 per minute. Acrocyanosis and overlapping sutures (molding) are normal findings
in the immediate neonatal period.
5. A nurse is caring for a client who is at 32 weeks of gestation and has preeclampsia. Which
of the following findings is the priority for the nurse to report to the provider?
A. 1+ pitting edema in the lower extremities.
B. Continuous headache that is unresponsive to analgesics.
C. Weight gain of 1 lb (0.45 kg) in one week.
D. Blood pressure of 148/92 mmHg.
