NUR 202/NUR202 Exam 4 V3 | Maternal-Newborn
Nursing Q&A with Rationale | Fortis College
1. A nurse is monitoring a client who is receiving magnesium sulfate via IV infusion for
preeclampsia. Which of the following findings should the nurse report to the provider as a
sign of magnesium toxicity?
A. Deep tendon reflexes of 2+
B. Blood pressure of 150/95 mmHg
C. Respiratory rate of 14/min
D. Urine output of 20 mL/hr
Correct Answer: D
Explanation: A urine output of less than 30 mL/hr is a critical indicator of magnesium
toxicity because the drug is excreted by the kidneys. If kidney function decreases,
magnesium levels can rise to dangerous levels in the blood. The nurse must also monitor
for decreased deep tendon reflexes and respiratory depression under 12/min.
2. A nurse is caring for a newborn immediately following birth. After ensuring the airway is
clear, which of the following is the priority action for the nurse to take?
A. Administer Vitamin K intramuscularly
B. Apply erythromycin ophthalmic ointment
C. Perform the initial APGAR score assessment
,D. Dry the newborn and place them skin-to-skin
Correct Answer: D
Explanation: Newborns are at high risk for cold stress due to their large surface area and
limited brown fat. Drying the infant and providing skin-to-skin contact with the mother
prevents heat loss via evaporation and conduction. Maintaining thermoregulation is a
physiological priority over secondary tasks like medication administration.
3. A nurse is assessing 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 10 units IM
B. Perform a fundal massage for 15 minutes
C. Notify the provider of a possible hemorrhage
D. Assist the client to the bathroom to void
Correct Answer: D
Explanation: A displaced uterus to the right is a classic sign of bladder distention. A full
bladder prevents the uterus from contracting effectively, which increases the risk of
postpartum hemorrhage. Assisting the client to empty her bladder is the most appropriate
initial nursing intervention to resolve displacement.
, 4. A nurse is providing teaching to a client who is at 30 weeks of gestation and has a new
diagnosis of gestational diabetes. Which of the following statements by the client indicates
an understanding of the teaching?
A. I will check my blood glucose levels before every meal.
B. I will limit my carbohydrate intake to 20% of my total calories.
C. I should avoid exercise to prevent low blood sugar episodes.
D. I will need to take oral hypoglycemic agents until I deliver.
Correct Answer: A
Explanation: Clients with gestational diabetes must monitor blood glucose levels closely,
usually four to six times a day, including before and after meals. Carbohydrate intake
should generally be 40% to 50% of daily calories to provide adequate energy for the fetus.
Regular exercise is actually encouraged to help stabilize blood glucose levels.
5. A nurse is caring for a newborn whose mother has a history of opioid use disorder. Which
of the following findings should the nurse expect to see?
A. Lethargy and poor muscle tone
B. Excessive sneezing and high-pitched cry
C. Low-pitched grunt during expiration
D. Sunken fontanels and dry mucous membranes
Correct Answer: B
Nursing Q&A with Rationale | Fortis College
1. A nurse is monitoring a client who is receiving magnesium sulfate via IV infusion for
preeclampsia. Which of the following findings should the nurse report to the provider as a
sign of magnesium toxicity?
A. Deep tendon reflexes of 2+
B. Blood pressure of 150/95 mmHg
C. Respiratory rate of 14/min
D. Urine output of 20 mL/hr
Correct Answer: D
Explanation: A urine output of less than 30 mL/hr is a critical indicator of magnesium
toxicity because the drug is excreted by the kidneys. If kidney function decreases,
magnesium levels can rise to dangerous levels in the blood. The nurse must also monitor
for decreased deep tendon reflexes and respiratory depression under 12/min.
2. A nurse is caring for a newborn immediately following birth. After ensuring the airway is
clear, which of the following is the priority action for the nurse to take?
A. Administer Vitamin K intramuscularly
B. Apply erythromycin ophthalmic ointment
C. Perform the initial APGAR score assessment
,D. Dry the newborn and place them skin-to-skin
Correct Answer: D
Explanation: Newborns are at high risk for cold stress due to their large surface area and
limited brown fat. Drying the infant and providing skin-to-skin contact with the mother
prevents heat loss via evaporation and conduction. Maintaining thermoregulation is a
physiological priority over secondary tasks like medication administration.
3. A nurse is assessing 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 10 units IM
B. Perform a fundal massage for 15 minutes
C. Notify the provider of a possible hemorrhage
D. Assist the client to the bathroom to void
Correct Answer: D
Explanation: A displaced uterus to the right is a classic sign of bladder distention. A full
bladder prevents the uterus from contracting effectively, which increases the risk of
postpartum hemorrhage. Assisting the client to empty her bladder is the most appropriate
initial nursing intervention to resolve displacement.
, 4. A nurse is providing teaching to a client who is at 30 weeks of gestation and has a new
diagnosis of gestational diabetes. Which of the following statements by the client indicates
an understanding of the teaching?
A. I will check my blood glucose levels before every meal.
B. I will limit my carbohydrate intake to 20% of my total calories.
C. I should avoid exercise to prevent low blood sugar episodes.
D. I will need to take oral hypoglycemic agents until I deliver.
Correct Answer: A
Explanation: Clients with gestational diabetes must monitor blood glucose levels closely,
usually four to six times a day, including before and after meals. Carbohydrate intake
should generally be 40% to 50% of daily calories to provide adequate energy for the fetus.
Regular exercise is actually encouraged to help stabilize blood glucose levels.
5. A nurse is caring for a newborn whose mother has a history of opioid use disorder. Which
of the following findings should the nurse expect to see?
A. Lethargy and poor muscle tone
B. Excessive sneezing and high-pitched cry
C. Low-pitched grunt during expiration
D. Sunken fontanels and dry mucous membranes
Correct Answer: B
