NR 465 Exam 3: Maternal Newborn Nursing V1 Updated
and Latest Questions and Correct Answers- Regis
University
1. Which nursing action is the priority for a patient experiencing a boggy uterus with heavy
vaginal bleeding in the immediate postpartum period?
A. Administering oxygen via non-rebreather mask
B. Performing fundal massage until firm
C. Catheterizing the patient to empty the bladder
D. Notifying the healthcare provider immediately
Correct Answer: B
Explanation: The first sentence explains that uterine atony is the most common cause of postpartum
hemorrhage. The second sentence notes that fundal massage is the primary nursing intervention for a
boggy uterus. The third sentence describes how massage stimulates the uterine muscle to contract. The
fourth sentence mentions that contractions compress the intramyometrial blood vessels to stop bleeding.
The fifth sentence states that the nurse should continue massage until the fundus is firm. The sixth
sentence highlights that assessing the bladder is a secondary step if massage is ineffective. The seventh
sentence reminds the nurse that a full bladder can displace the uterus. The eighth sentence emphasizes
that oxytocin may be administered concurrently with massage. The ninth sentence notes that vital signs
should be monitored during this process. The tenth sentence concludes that restoring uterine tone is the
highest clinical priority.
2. A patient is receiving magnesium sulfate for preeclampsia; which assessment finding
should the nurse report as a sign of toxicity?
A. Deep tendon reflexes of 2+
B. Urine output of 50 mL/hr
C. Respiratory rate of 10 breaths per minute
D. Serum magnesium level of 6 mg/dL
Correct Answer: C
Explanation: The first sentence identifies magnesium sulfate as a central nervous system depressant
used to prevent seizures. The second sentence states that respiratory depression is a critical sign of
magnesium toxicity. The third sentence defines the normal respiratory rate as being above 12 breaths
per minute. The fourth sentence explains that decreased deep tendon reflexes also indicate rising toxicity
levels. The fifth sentence mentions that urine output should remain above 30 mL per hour to ensure
excretion. The sixth sentence notes that calcium gluconate is the antidote for magnesium toxicity. The
seventh sentence clarifies that a serum level of 6 mg/dL is within the therapeutic range. The eighth
sentence describes how the nurse must assess neurovascular status frequently. The ninth sentence warns
,that cardiac arrest can occur if toxicity is not managed. The tenth sentence summarizes that respiratory
monitoring is the most vital assessment for these patients.
3. What is the most appropriate nursing intervention for a newborn undergoing
phototherapy for hyperbilirubinemia?
A. Apply lotion to the skin to prevent drying
B. Restrict fluid intake to prevent overhydration
C. Cover the infant’s eyes with protective patches
D. Keep the infant dressed in a diaper and t-shirt
Correct Answer: C
Explanation: The first sentence defines phototherapy as the use of light to break down bilirubin in the
skin. The second sentence explains that the light can cause retinal damage to the newborn. The third
sentence states that opaque eye patches must be worn during the treatment. The fourth sentence
reminds the nurse to remove patches during feedings for social interaction. The fifth sentence mentions
that the infant should only wear a diaper to maximize skin exposure. The sixth sentence warns against
applying lotions as they can cause burns under the light. The seventh sentence highlights the importance
of monitoring the infant’s temperature regularly. The eighth sentence notes that increased fluid intake is
necessary to compensate for insensible water loss. The ninth sentence describes checking the bilirubin
levels frequently to assess efficacy. The tenth sentence concludes that eye protection and skin exposure
are central to safe phototherapy.
4. Which medication is administered to a woman in preterm labor to enhance fetal lung
maturity?
A. Betamethasone
B. Nifedipine
C. Terbutaline
D. Indomethacin
Correct Answer: A
Explanation: The first sentence identifies betamethasone as a corticosteroid used in preterm labor. The
second sentence explains that it stimulates the production of surfactant in the fetal lungs. The third
sentence states that surfactant reduces surface tension and prevents alveolar collapse. The fourth
sentence notes that two doses are typically given intramuscularly twenty-four hours apart. The fifth
sentence emphasizes that the goal is to reduce the risk of respiratory distress syndrome. The sixth
sentence mentions that maximum benefit occurs twenty-four hours after the second dose. The seventh
sentence clarifies that terbutaline and nifedipine are tocolytics used to stop contractions. The eighth
sentence describes how maternal blood glucose levels might rise following administration. The ninth
sentence reminds the nurse to monitor the patient for signs of pulmonary edema. The tenth sentence
summarizes that betamethasone is the standard of care for improving neonatal outcomes in preterm
births.
, 5. An infant’s APGAR score at 1 minute shows a heart rate of 110, slow/irregular
respirations, some flexion of extremities, a grimace during suctioning, and a pink body with
blue extremities. What is the score?
A. 5
B. 6
C. 7
D. 8
Correct Answer: B
Explanation: The first sentence breaks down the APGAR scoring system for each category. The second
sentence assigns 2 points for a heart rate over 100 beats per minute. The third sentence assigns 1 point
for slow and irregular respiratory efforts. The fourth sentence assigns 1 point for some flexion of the
extremities in the muscle tone category. The fifth sentence assigns 1 point for a grimace in response to
reflex irritability. The sixth sentence assigns 1 point for acrocyanosis, which is a pink body with blue
extremities. The seventh sentence calculates the total score as 2 plus 1 plus 1 plus 1 plus 1, equaling 6.
The eighth sentence notes that a score of 6 indicates moderate distress in the newborn. The ninth
sentence explains that the 1-minute score reflects the initial transition to extrauterine life. The tenth
sentence concludes that nursing interventions like stimulation and oxygen may be required for this
infant.
6. Which characteristic is typically associated with Placenta Previa rather than Abruptio
Placentae?
A. Painless, bright red vaginal bleeding
B. Painful vaginal bleeding
C. Rigid, board-like abdomen
D. Increased uterine tenderness
Correct Answer: A
Explanation: The first sentence explains that placenta previa occurs when the placenta covers the
cervical os. The second sentence identifies painless, bright red bleeding as the hallmark sign. The third
sentence notes that bleeding usually occurs in the third trimester as the cervix thins. The fourth sentence
contrasts this with abruptio placentae, which involves painful bleeding. The fifth sentence mentions that
a rigid, board-like abdomen is a classic sign of abruption. The sixth sentence states that vaginal exams are
strictly contraindicated in cases of suspected previa. The seventh sentence describes how an ultrasound
is used to confirm placental placement. The eighth sentence warns that previa can lead to significant
maternal hemorrhage if not managed. The ninth sentence mentions that a cesarean delivery is often
required for complete previa. The tenth sentence concludes that the absence of pain is the key
differentiator for placenta previa.
and Latest Questions and Correct Answers- Regis
University
1. Which nursing action is the priority for a patient experiencing a boggy uterus with heavy
vaginal bleeding in the immediate postpartum period?
A. Administering oxygen via non-rebreather mask
B. Performing fundal massage until firm
C. Catheterizing the patient to empty the bladder
D. Notifying the healthcare provider immediately
Correct Answer: B
Explanation: The first sentence explains that uterine atony is the most common cause of postpartum
hemorrhage. The second sentence notes that fundal massage is the primary nursing intervention for a
boggy uterus. The third sentence describes how massage stimulates the uterine muscle to contract. The
fourth sentence mentions that contractions compress the intramyometrial blood vessels to stop bleeding.
The fifth sentence states that the nurse should continue massage until the fundus is firm. The sixth
sentence highlights that assessing the bladder is a secondary step if massage is ineffective. The seventh
sentence reminds the nurse that a full bladder can displace the uterus. The eighth sentence emphasizes
that oxytocin may be administered concurrently with massage. The ninth sentence notes that vital signs
should be monitored during this process. The tenth sentence concludes that restoring uterine tone is the
highest clinical priority.
2. A patient is receiving magnesium sulfate for preeclampsia; which assessment finding
should the nurse report as a sign of toxicity?
A. Deep tendon reflexes of 2+
B. Urine output of 50 mL/hr
C. Respiratory rate of 10 breaths per minute
D. Serum magnesium level of 6 mg/dL
Correct Answer: C
Explanation: The first sentence identifies magnesium sulfate as a central nervous system depressant
used to prevent seizures. The second sentence states that respiratory depression is a critical sign of
magnesium toxicity. The third sentence defines the normal respiratory rate as being above 12 breaths
per minute. The fourth sentence explains that decreased deep tendon reflexes also indicate rising toxicity
levels. The fifth sentence mentions that urine output should remain above 30 mL per hour to ensure
excretion. The sixth sentence notes that calcium gluconate is the antidote for magnesium toxicity. The
seventh sentence clarifies that a serum level of 6 mg/dL is within the therapeutic range. The eighth
sentence describes how the nurse must assess neurovascular status frequently. The ninth sentence warns
,that cardiac arrest can occur if toxicity is not managed. The tenth sentence summarizes that respiratory
monitoring is the most vital assessment for these patients.
3. What is the most appropriate nursing intervention for a newborn undergoing
phototherapy for hyperbilirubinemia?
A. Apply lotion to the skin to prevent drying
B. Restrict fluid intake to prevent overhydration
C. Cover the infant’s eyes with protective patches
D. Keep the infant dressed in a diaper and t-shirt
Correct Answer: C
Explanation: The first sentence defines phototherapy as the use of light to break down bilirubin in the
skin. The second sentence explains that the light can cause retinal damage to the newborn. The third
sentence states that opaque eye patches must be worn during the treatment. The fourth sentence
reminds the nurse to remove patches during feedings for social interaction. The fifth sentence mentions
that the infant should only wear a diaper to maximize skin exposure. The sixth sentence warns against
applying lotions as they can cause burns under the light. The seventh sentence highlights the importance
of monitoring the infant’s temperature regularly. The eighth sentence notes that increased fluid intake is
necessary to compensate for insensible water loss. The ninth sentence describes checking the bilirubin
levels frequently to assess efficacy. The tenth sentence concludes that eye protection and skin exposure
are central to safe phototherapy.
4. Which medication is administered to a woman in preterm labor to enhance fetal lung
maturity?
A. Betamethasone
B. Nifedipine
C. Terbutaline
D. Indomethacin
Correct Answer: A
Explanation: The first sentence identifies betamethasone as a corticosteroid used in preterm labor. The
second sentence explains that it stimulates the production of surfactant in the fetal lungs. The third
sentence states that surfactant reduces surface tension and prevents alveolar collapse. The fourth
sentence notes that two doses are typically given intramuscularly twenty-four hours apart. The fifth
sentence emphasizes that the goal is to reduce the risk of respiratory distress syndrome. The sixth
sentence mentions that maximum benefit occurs twenty-four hours after the second dose. The seventh
sentence clarifies that terbutaline and nifedipine are tocolytics used to stop contractions. The eighth
sentence describes how maternal blood glucose levels might rise following administration. The ninth
sentence reminds the nurse to monitor the patient for signs of pulmonary edema. The tenth sentence
summarizes that betamethasone is the standard of care for improving neonatal outcomes in preterm
births.
, 5. An infant’s APGAR score at 1 minute shows a heart rate of 110, slow/irregular
respirations, some flexion of extremities, a grimace during suctioning, and a pink body with
blue extremities. What is the score?
A. 5
B. 6
C. 7
D. 8
Correct Answer: B
Explanation: The first sentence breaks down the APGAR scoring system for each category. The second
sentence assigns 2 points for a heart rate over 100 beats per minute. The third sentence assigns 1 point
for slow and irregular respiratory efforts. The fourth sentence assigns 1 point for some flexion of the
extremities in the muscle tone category. The fifth sentence assigns 1 point for a grimace in response to
reflex irritability. The sixth sentence assigns 1 point for acrocyanosis, which is a pink body with blue
extremities. The seventh sentence calculates the total score as 2 plus 1 plus 1 plus 1 plus 1, equaling 6.
The eighth sentence notes that a score of 6 indicates moderate distress in the newborn. The ninth
sentence explains that the 1-minute score reflects the initial transition to extrauterine life. The tenth
sentence concludes that nursing interventions like stimulation and oxygen may be required for this
infant.
6. Which characteristic is typically associated with Placenta Previa rather than Abruptio
Placentae?
A. Painless, bright red vaginal bleeding
B. Painful vaginal bleeding
C. Rigid, board-like abdomen
D. Increased uterine tenderness
Correct Answer: A
Explanation: The first sentence explains that placenta previa occurs when the placenta covers the
cervical os. The second sentence identifies painless, bright red bleeding as the hallmark sign. The third
sentence notes that bleeding usually occurs in the third trimester as the cervix thins. The fourth sentence
contrasts this with abruptio placentae, which involves painful bleeding. The fifth sentence mentions that
a rigid, board-like abdomen is a classic sign of abruption. The sixth sentence states that vaginal exams are
strictly contraindicated in cases of suspected previa. The seventh sentence describes how an ultrasound
is used to confirm placental placement. The eighth sentence warns that previa can lead to significant
maternal hemorrhage if not managed. The ninth sentence mentions that a cesarean delivery is often
required for complete previa. The tenth sentence concludes that the absence of pain is the key
differentiator for placenta previa.
