NR 465 Exam 3: Maternal Newborn Nursing V2 UP-
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1. A nurse is caring for a client at 32 weeks gestation with a blood pressure of
140/94 mm Hg and 1+ proteinuria. Which criteria does this clinical picture best fit?
A. Chronic hypertension
B. Gestational hypertension
C. Preeclampsia
D. Normal pregnancy finding
Correct Answer: C. Preeclampsia
Explanation: Preeclampsia is defined as new-onset hypertension (BP ≥140/90) after 20
weeks gestation accompanied by proteinuria or other signs of end-organ dysfunction .
Chronic hypertension would have been present before pregnancy or diagnosed early in
gestation. Gestational hypertension involves elevated BP without proteinuria.
2. A nurse is caring for a client receiving magnesium sulfate for severe
preeclampsia. Which assessment finding is the highest priority to report to the
provider?
A. Urinary output of 25 mL/hour
B. Deep tendon reflexes of 2+
C. Respiratory rate of 20 breaths/minute
D. Client reports a mild headache
Correct Answer: A. Urinary output of 25 mL/hour
Explanation: Magnesium sulfate is excreted renally, so adequate urine output is critical
to prevent toxicity. A urinary output of <30 mL/hour indicates the kidneys are not
clearing the medication, putting the patient at risk for magnesium toxicity, which can
lead to respiratory depression and cardiac arrest . The nurse should report this
immediately.
3. A nurse is monitoring a laboring client receiving oxytocin (Pitocin). Which fetal
heart rate pattern requires the nurse to take immediate action?
,A. Early decelerations
B. Accelerations with fetal movement
C. Late decelerations
D. Moderate variability
Correct Answer: C. Late decelerations
Explanation: Late decelerations are a non-reassuring pattern indicating uteroplacental
insufficiency, meaning the fetus is not receiving adequate oxygen during contractions. If
this occurs during an oxytocin infusion, the nurse must stop the infusion immediately
and notify the provider .
4. A nurse is assessing a newborn who is 1 hour old. Which finding should the
nurse report to the provider?
A. Acrocyanosis of the hands and feet
B. Heart rate of 140 beats per minute
C. Generalized petechiae across the trunk and back
D. Respiratory rate of 50 breaths per minute
Correct Answer: C. Generalized petechiae across the trunk and back
Explanation: While localized petechiae on the presenting part (e.g., the face or scalp)
can be normal due to birth trauma, generalized petechiae are concerning. This finding
can indicate a low platelet count (thrombocytopenia), infection, or a clotting disorder .
Acrocyanosis (blue hands/feet) is a normal finding in the first 24 hours.
5. A nurse is providing discharge teaching to a client who is Rh-negative and just
gave birth to an Rh-positive infant. The client asks why she needs to receive
Rho(D) immune globulin (RhoGAM). Which is the nurse's best response?
A. "It treats the mild anemia your baby has due to blood type incompatibility."
B. "It prevents your body from making antibodies that could harm a future pregnancy."
C. "It destroys the Rh-positive blood cells currently circulating in your bloodstream."
D. "It helps your bone marrow produce more red blood cells to prevent anemia."
Correct Answer: B. "It prevents your body from making antibodies that could harm
a future pregnancy."
Explanation: RhoGAM works by suppressing the mother's immune response so she
does not produce anti-Rh antibodies. If she becomes pregnant with another Rh-positive
baby in the future, the antibodies she is forming now could attack the new baby's red
blood cells, causing hemolytic disease of the newborn .
,6. A nurse is reviewing risks associated with forceps-assisted delivery. Which
complication is specifically associated with this procedure?
A. Intrauterine growth restriction (IUGR)
B. Cephalohematoma
C. Maternal bradycardia
D. Fetal tachycardia
Correct Answer: B. Cephalohematoma
Explanation: Forceps delivery involves applying pressure to the fetal skull to assist birth.
This trauma can rupture blood vessels between the periosteum and the skull bone,
leading to a cephalohematoma (a collection of blood that does not cross suture lines) .
7. A nurse is caring for a client who tests positive for Group B Streptococcus (GBS).
What is the priority nursing action during labor?
A. Prepare the client for a cesarean birth
B. Educate the client on signs of newborn infection
C. Administer intrapartum prophylactic antibiotics
D. Notify the NICU team to be present at birth
Correct Answer: C. Administer intrapartum prophylactic antibiotics
Explanation: Prophylactic antibiotics (typically Penicillin G or Ampicillin) are the
standard of care to prevent early-onset GBS disease in the newborn. They must be given
intravenously for at least 4 hours before delivery to be effective.
8. A client who is 34 weeks pregnant presents with painless, bright red vaginal
bleeding. The nurse suspects placenta previa. What is the appropriate nursing
action?
A. Perform a digital cervical exam to assess dilation
B. Prepare to administer magnesium sulfate
C. Place the client in a knee-chest position
D. Avoid vaginal exams and prepare for an ultrasound
Correct Answer: D. Avoid vaginal exams and prepare for an ultrasound
Explanation: Digital cervical exams are contraindicated in suspected placenta previa
because they can disrupt the placental attachment and cause catastrophic hemorrhage.
The priority is to confirm the diagnosis via ultrasound while monitoring the mother and
fetus.
, 9. A nurse is assessing a client 6 hours after a vaginal delivery. The fundus is firm
and deviated to the right side of the umbilicus. What is the nurse's priority action?
A. Massage the fundus firmly
B. Assist the client to empty her bladder
C. Notify the provider immediately
D. Increase the IV oxytocin (Pitocin) rate
Correct Answer: B. Assist the client to empty her bladder
Explanation: A deviated (usually to the right) and elevated fundus is a classic sign of a
distended bladder, which displaces the uterus and prevents it from contracting
effectively. Emptying the bladder allows the uterus to return to midline, which is often all
that is needed to resolve the displacement.
10. A newborn is born to a mother who used opioids throughout pregnancy.
Which finding indicates the newborn is experiencing neonatal abstinence
syndrome (NAS)?
A. Lethargy and weak Moro reflex
B. Hypertonicity and a high-pitched cry
C. Depressed respiratory drive
D. Absence of the rooting reflex
Correct Answer: B. Hypertonicity and a high-pitched cry
Explanation: NAS presents with signs of central nervous system hyperirritability. This
includes a high-pitched, continuous cry, hypertonia (stiff muscles), tremors, poor
feeding, and vomiting. They are overstimulated, not lethargic .
11. A nurse is assessing a newborn who is 12 hours old. Which of the following
findings should the nurse expect?
A. Presence of the Babinski reflex
B. Jaundice on the face
C. Blood pressure of 110/70 mm Hg
D. Regurgitation of all feedings
Correct Answer: A. Presence of the Babinski reflex
*Explanation: The Babinski reflex (toes fan out when sole of foot is stroked) is a normal
primitive reflex in newborns and persists until approximately 12–24 months of age .
Jaundice within the first 24 hours of life is pathologic and requires investigation. Normal
TO-DATE EXAM QUESTIONS AND 100% ACCURATE
SOLUTIONS | VERIFIED ANSWERS - INSTANT PDF
DOWNLOAD. Regis University
1. A nurse is caring for a client at 32 weeks gestation with a blood pressure of
140/94 mm Hg and 1+ proteinuria. Which criteria does this clinical picture best fit?
A. Chronic hypertension
B. Gestational hypertension
C. Preeclampsia
D. Normal pregnancy finding
Correct Answer: C. Preeclampsia
Explanation: Preeclampsia is defined as new-onset hypertension (BP ≥140/90) after 20
weeks gestation accompanied by proteinuria or other signs of end-organ dysfunction .
Chronic hypertension would have been present before pregnancy or diagnosed early in
gestation. Gestational hypertension involves elevated BP without proteinuria.
2. A nurse is caring for a client receiving magnesium sulfate for severe
preeclampsia. Which assessment finding is the highest priority to report to the
provider?
A. Urinary output of 25 mL/hour
B. Deep tendon reflexes of 2+
C. Respiratory rate of 20 breaths/minute
D. Client reports a mild headache
Correct Answer: A. Urinary output of 25 mL/hour
Explanation: Magnesium sulfate is excreted renally, so adequate urine output is critical
to prevent toxicity. A urinary output of <30 mL/hour indicates the kidneys are not
clearing the medication, putting the patient at risk for magnesium toxicity, which can
lead to respiratory depression and cardiac arrest . The nurse should report this
immediately.
3. A nurse is monitoring a laboring client receiving oxytocin (Pitocin). Which fetal
heart rate pattern requires the nurse to take immediate action?
,A. Early decelerations
B. Accelerations with fetal movement
C. Late decelerations
D. Moderate variability
Correct Answer: C. Late decelerations
Explanation: Late decelerations are a non-reassuring pattern indicating uteroplacental
insufficiency, meaning the fetus is not receiving adequate oxygen during contractions. If
this occurs during an oxytocin infusion, the nurse must stop the infusion immediately
and notify the provider .
4. A nurse is assessing a newborn who is 1 hour old. Which finding should the
nurse report to the provider?
A. Acrocyanosis of the hands and feet
B. Heart rate of 140 beats per minute
C. Generalized petechiae across the trunk and back
D. Respiratory rate of 50 breaths per minute
Correct Answer: C. Generalized petechiae across the trunk and back
Explanation: While localized petechiae on the presenting part (e.g., the face or scalp)
can be normal due to birth trauma, generalized petechiae are concerning. This finding
can indicate a low platelet count (thrombocytopenia), infection, or a clotting disorder .
Acrocyanosis (blue hands/feet) is a normal finding in the first 24 hours.
5. A nurse is providing discharge teaching to a client who is Rh-negative and just
gave birth to an Rh-positive infant. The client asks why she needs to receive
Rho(D) immune globulin (RhoGAM). Which is the nurse's best response?
A. "It treats the mild anemia your baby has due to blood type incompatibility."
B. "It prevents your body from making antibodies that could harm a future pregnancy."
C. "It destroys the Rh-positive blood cells currently circulating in your bloodstream."
D. "It helps your bone marrow produce more red blood cells to prevent anemia."
Correct Answer: B. "It prevents your body from making antibodies that could harm
a future pregnancy."
Explanation: RhoGAM works by suppressing the mother's immune response so she
does not produce anti-Rh antibodies. If she becomes pregnant with another Rh-positive
baby in the future, the antibodies she is forming now could attack the new baby's red
blood cells, causing hemolytic disease of the newborn .
,6. A nurse is reviewing risks associated with forceps-assisted delivery. Which
complication is specifically associated with this procedure?
A. Intrauterine growth restriction (IUGR)
B. Cephalohematoma
C. Maternal bradycardia
D. Fetal tachycardia
Correct Answer: B. Cephalohematoma
Explanation: Forceps delivery involves applying pressure to the fetal skull to assist birth.
This trauma can rupture blood vessels between the periosteum and the skull bone,
leading to a cephalohematoma (a collection of blood that does not cross suture lines) .
7. A nurse is caring for a client who tests positive for Group B Streptococcus (GBS).
What is the priority nursing action during labor?
A. Prepare the client for a cesarean birth
B. Educate the client on signs of newborn infection
C. Administer intrapartum prophylactic antibiotics
D. Notify the NICU team to be present at birth
Correct Answer: C. Administer intrapartum prophylactic antibiotics
Explanation: Prophylactic antibiotics (typically Penicillin G or Ampicillin) are the
standard of care to prevent early-onset GBS disease in the newborn. They must be given
intravenously for at least 4 hours before delivery to be effective.
8. A client who is 34 weeks pregnant presents with painless, bright red vaginal
bleeding. The nurse suspects placenta previa. What is the appropriate nursing
action?
A. Perform a digital cervical exam to assess dilation
B. Prepare to administer magnesium sulfate
C. Place the client in a knee-chest position
D. Avoid vaginal exams and prepare for an ultrasound
Correct Answer: D. Avoid vaginal exams and prepare for an ultrasound
Explanation: Digital cervical exams are contraindicated in suspected placenta previa
because they can disrupt the placental attachment and cause catastrophic hemorrhage.
The priority is to confirm the diagnosis via ultrasound while monitoring the mother and
fetus.
, 9. A nurse is assessing a client 6 hours after a vaginal delivery. The fundus is firm
and deviated to the right side of the umbilicus. What is the nurse's priority action?
A. Massage the fundus firmly
B. Assist the client to empty her bladder
C. Notify the provider immediately
D. Increase the IV oxytocin (Pitocin) rate
Correct Answer: B. Assist the client to empty her bladder
Explanation: A deviated (usually to the right) and elevated fundus is a classic sign of a
distended bladder, which displaces the uterus and prevents it from contracting
effectively. Emptying the bladder allows the uterus to return to midline, which is often all
that is needed to resolve the displacement.
10. A newborn is born to a mother who used opioids throughout pregnancy.
Which finding indicates the newborn is experiencing neonatal abstinence
syndrome (NAS)?
A. Lethargy and weak Moro reflex
B. Hypertonicity and a high-pitched cry
C. Depressed respiratory drive
D. Absence of the rooting reflex
Correct Answer: B. Hypertonicity and a high-pitched cry
Explanation: NAS presents with signs of central nervous system hyperirritability. This
includes a high-pitched, continuous cry, hypertonia (stiff muscles), tremors, poor
feeding, and vomiting. They are overstimulated, not lethargic .
11. A nurse is assessing a newborn who is 12 hours old. Which of the following
findings should the nurse expect?
A. Presence of the Babinski reflex
B. Jaundice on the face
C. Blood pressure of 110/70 mm Hg
D. Regurgitation of all feedings
Correct Answer: A. Presence of the Babinski reflex
*Explanation: The Babinski reflex (toes fan out when sole of foot is stroked) is a normal
primitive reflex in newborns and persists until approximately 12–24 months of age .
Jaundice within the first 24 hours of life is pathologic and requires investigation. Normal
