PNR 203/PNR203 Final Exam V3 |
Maternal-Newborn Nursing Q&A with
Rationale | Fortis College
1. A nurse is assessing a newborn at 1 minute after birth. The newborn has a heart rate of
110/min, a slow and irregular respiratory effort, some flexion of the extremities, a grimace in
response to suctioning, and a pink body with blue extremities. Which APGAR score should the
nurse assign?
A. 5
B. 8
C. 7
D. 6
Correct Answer: D
Expert Explanation: The APGAR score is calculated based on five criteria, each worth 0-2
points. In this case, heart rate >100 is 2, slow/irregular respirations is 1, some flexion is 1,
grimace is 1, and acrocyanosis is 1, totaling 6. Scores between 4 and 6 indicate that the
newborn is having some difficulty adjusting to extrauterine life and requires intervention.
,2. A nurse is caring for a client who is at 34 weeks of gestation and is receiving magnesium
sulfate for preeclampsia. Which of the following findings should the nurse identify as a sign of
magnesium toxicity?
A. Presence of a fetal heart rate of 140/min
B. Increased urinary output
C. Hyperreflexia (3+ deep tendon reflexes)
D. Respiratory rate of 10/min
Correct Answer: D
Expert Explanation: Magnesium sulfate is a central nervous system depressant used to
prevent seizures in preeclampsia. Toxicity manifests as respiratory depression (less than
12/min), loss of deep tendon reflexes, and decreased urinary output. The nurse must
monitor the client closely and have calcium gluconate available as an antidote.
3. Which of the following interventions should a nurse perform first when managing a client
who is experiencing a prolapsed umbilical cord?
A. Apply oxygen via nonrebreather mask at 10 L/min
B. Position the client in a knee-chest or Trendelenburg position
C. Manually apply upward pressure against the presenting part
D. Prepare the client for an immediate cesarean birth
Correct Answer: C
, Expert Explanation: Manually pushing the presenting part off the cord is the priority
action to restore fetal blood flow. This immediate relief of pressure prevents fetal hypoxia
while further emergency measures are initiated. The nurse should keep the hand in place
until the delivery of the baby occurs via cesarean section.
4. A nurse is providing teaching to a client who is at 12 weeks of gestation and has a new
prescription for an iron supplement. Which of the following instructions should the nurse
include?
A. Take the medication on an empty stomach if tolerated
B. Avoid taking the supplement with orange juice
C. Take the medication with a glass of milk
D. Expect the stools to become clay-colored
Correct Answer: A
Expert Explanation: Iron is best absorbed when taken on an empty stomach or with a
source of Vitamin C like orange juice. Calcium in milk can inhibit the absorption of iron and
should be avoided during administration. Clients should be warned that iron supplements
typically cause stools to appear dark green or black in color.
5. A client at 38 weeks of gestation reports a sudden onset of bright red vaginal bleeding
without pain. Which condition should the nurse suspect?
A. Abruptio placentae
B. Placenta previa
Maternal-Newborn Nursing Q&A with
Rationale | Fortis College
1. A nurse is assessing a newborn at 1 minute after birth. The newborn has a heart rate of
110/min, a slow and irregular respiratory effort, some flexion of the extremities, a grimace in
response to suctioning, and a pink body with blue extremities. Which APGAR score should the
nurse assign?
A. 5
B. 8
C. 7
D. 6
Correct Answer: D
Expert Explanation: The APGAR score is calculated based on five criteria, each worth 0-2
points. In this case, heart rate >100 is 2, slow/irregular respirations is 1, some flexion is 1,
grimace is 1, and acrocyanosis is 1, totaling 6. Scores between 4 and 6 indicate that the
newborn is having some difficulty adjusting to extrauterine life and requires intervention.
,2. A nurse is caring for a client who is at 34 weeks of gestation and is receiving magnesium
sulfate for preeclampsia. Which of the following findings should the nurse identify as a sign of
magnesium toxicity?
A. Presence of a fetal heart rate of 140/min
B. Increased urinary output
C. Hyperreflexia (3+ deep tendon reflexes)
D. Respiratory rate of 10/min
Correct Answer: D
Expert Explanation: Magnesium sulfate is a central nervous system depressant used to
prevent seizures in preeclampsia. Toxicity manifests as respiratory depression (less than
12/min), loss of deep tendon reflexes, and decreased urinary output. The nurse must
monitor the client closely and have calcium gluconate available as an antidote.
3. Which of the following interventions should a nurse perform first when managing a client
who is experiencing a prolapsed umbilical cord?
A. Apply oxygen via nonrebreather mask at 10 L/min
B. Position the client in a knee-chest or Trendelenburg position
C. Manually apply upward pressure against the presenting part
D. Prepare the client for an immediate cesarean birth
Correct Answer: C
, Expert Explanation: Manually pushing the presenting part off the cord is the priority
action to restore fetal blood flow. This immediate relief of pressure prevents fetal hypoxia
while further emergency measures are initiated. The nurse should keep the hand in place
until the delivery of the baby occurs via cesarean section.
4. A nurse is providing teaching to a client who is at 12 weeks of gestation and has a new
prescription for an iron supplement. Which of the following instructions should the nurse
include?
A. Take the medication on an empty stomach if tolerated
B. Avoid taking the supplement with orange juice
C. Take the medication with a glass of milk
D. Expect the stools to become clay-colored
Correct Answer: A
Expert Explanation: Iron is best absorbed when taken on an empty stomach or with a
source of Vitamin C like orange juice. Calcium in milk can inhibit the absorption of iron and
should be avoided during administration. Clients should be warned that iron supplements
typically cause stools to appear dark green or black in color.
5. A client at 38 weeks of gestation reports a sudden onset of bright red vaginal bleeding
without pain. Which condition should the nurse suspect?
A. Abruptio placentae
B. Placenta previa
