NUR202 MATERNAL NEWBORN
NURSING EXAM 2 200 ULTIMATE
Q&AS WITH BOLD ANSWERS &
EXPERT RATIONALES
NUR202 Maternal-Newborn Nursing Exam 2
Question 1
A nurse is assisting in the delivery of a full-term infant with anticipated
shoulder dystocia. Which potential skeletal injury should the nurse
closely monitor the newborn for post-delivery?
A. Fractured clavicle or humerus
B. Dislocated pelvic symphysis
C. Compressed lumbar vertebrae
D. Greenstick skull fracture [1, 2]
Rationale: Shoulder dystocia occurs when the infant's anterior
shoulder becomes impacted behind the maternal pubic bone. The
mechanical force required to maneuver and deliver the infant
significantly increases the risk of skeletal injuries, most notably a
fractured clavicle or a fractured humerus. Vertebral, pelvic, or skull
fractures are not typical outcomes of this specific delivery complication.
[1, 2]
Question 2
A nurse is reviewing the plan of care for a client diagnosed with
pregestational diabetes mellitus. Which of the following parameters
should the nurse identify as the primary daily measurement for
determining effective glycemic management?
A. Glycated hemoglobin (HbA1c) every 24 hours
B. Routine self-monitoring of blood glucose levels
C. Quantitative 24-hour urine protein levels
D. Continuous fetal heart rate variability tracking [1, 2]
,Rationale: Frequent self-monitoring of blood glucose levels throughout
the day (fasting, pre-prandial, and post-prandial) provides immediate
data needed to adjust diet, exercise, and insulin therapy on a daily
basis. HbA1c evaluates long-term control over 2 to 3 months rather
than daily variations. Urine protein checks for preeclampsia, not
glycemic compliance. [1]
Question 3
A nurse is caring for a client in preterm labor who is receiving an
intravenous infusion of terbutaline. Which of the following assessments
represents the priority nursing intervention?
A. Monitoring maternal deep tendon reflexes
B. Assessing maternal vital signs and fetal heart rate
C. Measuring maternal hourly urinary output
D. Assessing for signs of visual floaters [1, 2]
Rationale: Terbutaline is a beta-2 adrenergic agonist used to arrest
uterine contractions. Its most dangerous adverse effects include
maternal tachycardia, cardiac arrhythmias, and pulmonary edema.
Therefore, continuous or frequent assessment of maternal vital signs
and fetal heart rate is the highest priority. Assessing reflexes or visual
disturbances targets magnesium sulfate toxicity, not terbutaline. [1]
Question 4
A nurse is performing a localized postpartum assessment and notes
extensive bruising and localized swelling at the vulva. The client reports
severe, throbbing pelvic pain and has difficulty urinating. Which of the
following complications should the nurse suspect?
A. Uterine subinvolution
B. Retained placental fragments
C. Vulvar hematoma
D. Deep vein thrombosis [1]
Rationale: A vulvar hematoma is caused by rapid bleeding into the
surrounding subcutaneous tissues of the perineum, manifesting as
severe, unyielding pain, visual swelling, ecchymosis, and pressure that
frequently impairs voiding. Retained fragments and subinvolution
cause excessive vaginal bleeding, while a DVT causes unilateral calf
pain and swelling. [1]
Question 5
,A nurse is caring for a pregnant client who presents at 34 weeks of
gestation with a blood pressure reading of 145/92 mm Hg. There is no
prior history of chronic hypertension. How should the nurse classify this
baseline finding?
A. Chronic gestational hypertension
B. Severe eclampsia crisis
C. Gestational hypertension
D. Transient orthostatic hypotension [1]
Rationale: Gestational hypertension is defined as a blood pressure
elevation of 140/90 mm Hg or greater for the first time after 20 weeks
of gestation, without the concurrent presence of proteinuria or other
diagnostic systemic features of preeclampsia. Chronic hypertension
exists prior to pregnancy or before 20 weeks of gestation. [1]
Question 6
A nurse is conducting an admission assessment on a client at 36 weeks of
gestation who has been diagnosed with preeclampsia. Which of the
following systemic manifestations should the nurse identify as an
indicator that the condition is escalating to severe preeclampsia?
A. Dependent 1+ ankle edema at the end of the day
B. A persistent frontal headache unresponsive to
acetaminophen and hyperreflexia
C. A random blood glucose level of 110 mg/dL
D. Increased clear salivary secretions [1]
Rationale: Severe preeclampsia involves central nervous system
irritability due to cerebral vasospasms and edema. This manifests as a
severe, unremitting frontal headache, hyperreflexia, clonus, or visual
floaters/blurry vision. Mild dependent edema is a common, non-severe
feature of pregnancy, and blood glucose is unaffected. [1]
Question 7
A nurse is assessing a client with preeclampsia and tests for the presence
of clonus. Which of the following actions demonstrates the correct
technique for this assessment?
A. Striking the patellar tendon sharply with a reflex hammer.
B. Stroking the lateral aspect of the sole of the foot toward the toes.
C. Dorsiflexing the client's foot quickly, holding it, and
counting any rhythmic oscillations.
, D. Firmly squeezing the client's calf muscle while keeping the knee
flexed. [1]
Rationale: Clonus is evaluated by hyper-extending or briskly
dorsiflexing the foot, maintaining that stretch, and watching for
rhythmic, involuntary oscillations or beats as the foot falls back. The
number of twitches signifies the severity of neuromuscular irritability,
warning of an imminent seizure. [1]
Question 8
A nurse is caring for a client at 32 weeks of gestation who suddenly
experiences a generalized tonic-clonic seizure. Which of the following
conditions has occurred?
A. HELLP syndrome activation
B. Acute gestational stroke
C. Eclampsia
D. Amniotic fluid embolism [1]
Rationale: Eclampsia is clinically defined as the onset of new-onset
grand mal (tonic-clonic) seizures or coma in a client with preeclampsia
that cannot be attributed to other neurological causes. HELLP
syndrome involves laboratory hemolysis, liver enzyme elevations, and
low platelets but is not characterized solely by seizures. [1]
Question 9
A nurse is present at the bedside when a postpartum client with severe
preeclampsia begins having an eclamptic seizure. Which action must the
nurse prioritize during the active convulsion?
A. Promptly insert a padded wooden tongue blade into the mouth.
B. Turn the client onto their side, protect the airway, and
remain at the bedside.
C. Securely restrain all four extremities to the bed's side rails.
D. Immediately leave the room to find a mechanical airway trolley. [1, 2]
Rationale: During an active seizure, the primary safety goal is
protecting the airway and keeping the maternal patient safe from
injury. Placing the client in a lateral side-lying position promotes
drainage of oral secretions and reduces aspiration risks. Restraints or
foreign objects in the mouth cause tissue trauma; the nurse should
never leave the bedside. [1]
Question 10
NURSING EXAM 2 200 ULTIMATE
Q&AS WITH BOLD ANSWERS &
EXPERT RATIONALES
NUR202 Maternal-Newborn Nursing Exam 2
Question 1
A nurse is assisting in the delivery of a full-term infant with anticipated
shoulder dystocia. Which potential skeletal injury should the nurse
closely monitor the newborn for post-delivery?
A. Fractured clavicle or humerus
B. Dislocated pelvic symphysis
C. Compressed lumbar vertebrae
D. Greenstick skull fracture [1, 2]
Rationale: Shoulder dystocia occurs when the infant's anterior
shoulder becomes impacted behind the maternal pubic bone. The
mechanical force required to maneuver and deliver the infant
significantly increases the risk of skeletal injuries, most notably a
fractured clavicle or a fractured humerus. Vertebral, pelvic, or skull
fractures are not typical outcomes of this specific delivery complication.
[1, 2]
Question 2
A nurse is reviewing the plan of care for a client diagnosed with
pregestational diabetes mellitus. Which of the following parameters
should the nurse identify as the primary daily measurement for
determining effective glycemic management?
A. Glycated hemoglobin (HbA1c) every 24 hours
B. Routine self-monitoring of blood glucose levels
C. Quantitative 24-hour urine protein levels
D. Continuous fetal heart rate variability tracking [1, 2]
,Rationale: Frequent self-monitoring of blood glucose levels throughout
the day (fasting, pre-prandial, and post-prandial) provides immediate
data needed to adjust diet, exercise, and insulin therapy on a daily
basis. HbA1c evaluates long-term control over 2 to 3 months rather
than daily variations. Urine protein checks for preeclampsia, not
glycemic compliance. [1]
Question 3
A nurse is caring for a client in preterm labor who is receiving an
intravenous infusion of terbutaline. Which of the following assessments
represents the priority nursing intervention?
A. Monitoring maternal deep tendon reflexes
B. Assessing maternal vital signs and fetal heart rate
C. Measuring maternal hourly urinary output
D. Assessing for signs of visual floaters [1, 2]
Rationale: Terbutaline is a beta-2 adrenergic agonist used to arrest
uterine contractions. Its most dangerous adverse effects include
maternal tachycardia, cardiac arrhythmias, and pulmonary edema.
Therefore, continuous or frequent assessment of maternal vital signs
and fetal heart rate is the highest priority. Assessing reflexes or visual
disturbances targets magnesium sulfate toxicity, not terbutaline. [1]
Question 4
A nurse is performing a localized postpartum assessment and notes
extensive bruising and localized swelling at the vulva. The client reports
severe, throbbing pelvic pain and has difficulty urinating. Which of the
following complications should the nurse suspect?
A. Uterine subinvolution
B. Retained placental fragments
C. Vulvar hematoma
D. Deep vein thrombosis [1]
Rationale: A vulvar hematoma is caused by rapid bleeding into the
surrounding subcutaneous tissues of the perineum, manifesting as
severe, unyielding pain, visual swelling, ecchymosis, and pressure that
frequently impairs voiding. Retained fragments and subinvolution
cause excessive vaginal bleeding, while a DVT causes unilateral calf
pain and swelling. [1]
Question 5
,A nurse is caring for a pregnant client who presents at 34 weeks of
gestation with a blood pressure reading of 145/92 mm Hg. There is no
prior history of chronic hypertension. How should the nurse classify this
baseline finding?
A. Chronic gestational hypertension
B. Severe eclampsia crisis
C. Gestational hypertension
D. Transient orthostatic hypotension [1]
Rationale: Gestational hypertension is defined as a blood pressure
elevation of 140/90 mm Hg or greater for the first time after 20 weeks
of gestation, without the concurrent presence of proteinuria or other
diagnostic systemic features of preeclampsia. Chronic hypertension
exists prior to pregnancy or before 20 weeks of gestation. [1]
Question 6
A nurse is conducting an admission assessment on a client at 36 weeks of
gestation who has been diagnosed with preeclampsia. Which of the
following systemic manifestations should the nurse identify as an
indicator that the condition is escalating to severe preeclampsia?
A. Dependent 1+ ankle edema at the end of the day
B. A persistent frontal headache unresponsive to
acetaminophen and hyperreflexia
C. A random blood glucose level of 110 mg/dL
D. Increased clear salivary secretions [1]
Rationale: Severe preeclampsia involves central nervous system
irritability due to cerebral vasospasms and edema. This manifests as a
severe, unremitting frontal headache, hyperreflexia, clonus, or visual
floaters/blurry vision. Mild dependent edema is a common, non-severe
feature of pregnancy, and blood glucose is unaffected. [1]
Question 7
A nurse is assessing a client with preeclampsia and tests for the presence
of clonus. Which of the following actions demonstrates the correct
technique for this assessment?
A. Striking the patellar tendon sharply with a reflex hammer.
B. Stroking the lateral aspect of the sole of the foot toward the toes.
C. Dorsiflexing the client's foot quickly, holding it, and
counting any rhythmic oscillations.
, D. Firmly squeezing the client's calf muscle while keeping the knee
flexed. [1]
Rationale: Clonus is evaluated by hyper-extending or briskly
dorsiflexing the foot, maintaining that stretch, and watching for
rhythmic, involuntary oscillations or beats as the foot falls back. The
number of twitches signifies the severity of neuromuscular irritability,
warning of an imminent seizure. [1]
Question 8
A nurse is caring for a client at 32 weeks of gestation who suddenly
experiences a generalized tonic-clonic seizure. Which of the following
conditions has occurred?
A. HELLP syndrome activation
B. Acute gestational stroke
C. Eclampsia
D. Amniotic fluid embolism [1]
Rationale: Eclampsia is clinically defined as the onset of new-onset
grand mal (tonic-clonic) seizures or coma in a client with preeclampsia
that cannot be attributed to other neurological causes. HELLP
syndrome involves laboratory hemolysis, liver enzyme elevations, and
low platelets but is not characterized solely by seizures. [1]
Question 9
A nurse is present at the bedside when a postpartum client with severe
preeclampsia begins having an eclamptic seizure. Which action must the
nurse prioritize during the active convulsion?
A. Promptly insert a padded wooden tongue blade into the mouth.
B. Turn the client onto their side, protect the airway, and
remain at the bedside.
C. Securely restrain all four extremities to the bed's side rails.
D. Immediately leave the room to find a mechanical airway trolley. [1, 2]
Rationale: During an active seizure, the primary safety goal is
protecting the airway and keeping the maternal patient safe from
injury. Placing the client in a lateral side-lying position promotes
drainage of oral secretions and reduces aspiration risks. Restraints or
foreign objects in the mouth cause tissue trauma; the nurse should
never leave the bedside. [1]
Question 10
