NSG 432 Exam 3 V2 | NSG 432 Maternal-
Newborn Nursing / OB/GYN | Actual Q&A
with Rationale (NSG432 Exam 3) | Grand
Canyon University
1. A nurse is monitoring a postpartum client who is 2 hours post-delivery. Which of the
following assessment findings should the nurse prioritize as indicators of potential
postpartum hemorrhage? (Select all that apply)
A. Uterine fundus that is boggy or soft
B. Pulse rate of 115/min
C. Client reports feeling ‘chilled’
D. Saturation of a perineal pad in 15 minutes
E. Presence of large blood clots in the lochia
F. Blood pressure of 138/88 mmHg
Correct Answer: A, B, D, E
Uterine atony is the most common cause of postpartum hemorrhage and is characterized
by a boggy fundus. Tachycardia is an early compensatory sign of hypovolemia even before
a significant drop in blood pressure occurs. Rapid saturation of pads and large clots
indicate excessive bleeding that requires immediate massage of the fundus and possible
administration of uterotonic medications.
,2. A nurse is caring for a client with preeclampsia who is receiving a continuous intravenous
infusion of magnesium sulfate. Which of the following findings should the nurse report to the
provider as a sign of magnesium toxicity?
A. Fetal heart rate of 140/min
B. Urine output of 40 mL/hr
C. Blood pressure 150/95 mmHg
D. Absence of deep tendon reflexes
Correct Answer: D
The loss of deep tendon reflexes is one of the earliest signs of magnesium sulfate toxicity
and occurs before respiratory depression. The nurse must also monitor for a respiratory
rate below 12/min and a significant drop in urine output. If toxicity is suspected, the
infusion should be stopped immediately and calcium gluconate should be prepared for
administration.
3. A nurse is assessing a newborn 1 minute after birth and finds the following: heart rate
110/min, slow/irregular respiratory effort, some flexion of extremities, grimace in response
to a catheter in the nostril, and a pink body with blue extremities. What is the assigned
APGAR score?
A. 5
B. 7
C. 6
,D. 8
Correct Answer: C
The score is calculated as follows: Heart rate >100 is 2 points, slow/irregular respiration
is 1 point, some flexion is 1 point, grimace is 1 point, and acrocyanosis is 1 point. This total
leads to an APGAR score of 6, which indicates the newborn is having some difficulty
adjusting to extrauterine life. Scores between 4 and 6 usually require immediate
intervention such as suctioning or oxygen administration.
4. Which of the following interventions should the nurse include in the plan of care for a
newborn receiving phototherapy for hyperbilirubinemia? (Select all that apply)
A. Apply an opaque eye mask to the newborn
B. Apply lotion to the skin to prevent drying
C. Monitor the newborn’s temperature every 4 hours
D. Ensure the newborn is wearing only a diaper
E. Feed the newborn every 4 to 6 hours
F. Rotate the newborn every 2 to 3 hours
Correct Answer: A, C, D, F
Phototherapy requires maximum skin exposure, so only a diaper and eye protection
should be used to prevent retinal damage. The newborn is at risk for dehydration and
thermoregulation issues, requiring frequent temperature monitoring and feedings every 2
, to 3 hours. Repositioning the infant ensures that all skin surfaces are exposed to the light to
effectively break down bilirubin.
5. A nurse is preparing to administer Vitamin K (phytonadione) to a newborn. What is the
primary rationale for this medication?
A. To promote the synthesis of clotting factors
B. To prevent ophthalmia neonatorum
C. To stimulate the production of red blood cells
D. To enhance the immune system against sepsis
Correct Answer: A
Newborns are born with a sterile gut and lack the intestinal flora necessary to synthesize
Vitamin K. This deficiency leads to lower levels of clotting factors II, VII, IX, and X,
increasing the risk of Vitamin K deficiency bleeding (VKDB). A single intramuscular
injection of Vitamin K shortly after birth provides the necessary factors until the infant
starts producing it naturally.
6. A nurse is observing the fetal heart rate (FHR) monitor for a client in labor and notes late
decelerations. Which of the following actions should the nurse take first?
A. Assist the client into a side-lying position
B. Increase the rate of the oxytocin infusion
C. Perform a vaginal examination
Newborn Nursing / OB/GYN | Actual Q&A
with Rationale (NSG432 Exam 3) | Grand
Canyon University
1. A nurse is monitoring a postpartum client who is 2 hours post-delivery. Which of the
following assessment findings should the nurse prioritize as indicators of potential
postpartum hemorrhage? (Select all that apply)
A. Uterine fundus that is boggy or soft
B. Pulse rate of 115/min
C. Client reports feeling ‘chilled’
D. Saturation of a perineal pad in 15 minutes
E. Presence of large blood clots in the lochia
F. Blood pressure of 138/88 mmHg
Correct Answer: A, B, D, E
Uterine atony is the most common cause of postpartum hemorrhage and is characterized
by a boggy fundus. Tachycardia is an early compensatory sign of hypovolemia even before
a significant drop in blood pressure occurs. Rapid saturation of pads and large clots
indicate excessive bleeding that requires immediate massage of the fundus and possible
administration of uterotonic medications.
,2. A nurse is caring for a client with preeclampsia who is receiving a continuous intravenous
infusion of magnesium sulfate. Which of the following findings should the nurse report to the
provider as a sign of magnesium toxicity?
A. Fetal heart rate of 140/min
B. Urine output of 40 mL/hr
C. Blood pressure 150/95 mmHg
D. Absence of deep tendon reflexes
Correct Answer: D
The loss of deep tendon reflexes is one of the earliest signs of magnesium sulfate toxicity
and occurs before respiratory depression. The nurse must also monitor for a respiratory
rate below 12/min and a significant drop in urine output. If toxicity is suspected, the
infusion should be stopped immediately and calcium gluconate should be prepared for
administration.
3. A nurse is assessing a newborn 1 minute after birth and finds the following: heart rate
110/min, slow/irregular respiratory effort, some flexion of extremities, grimace in response
to a catheter in the nostril, and a pink body with blue extremities. What is the assigned
APGAR score?
A. 5
B. 7
C. 6
,D. 8
Correct Answer: C
The score is calculated as follows: Heart rate >100 is 2 points, slow/irregular respiration
is 1 point, some flexion is 1 point, grimace is 1 point, and acrocyanosis is 1 point. This total
leads to an APGAR score of 6, which indicates the newborn is having some difficulty
adjusting to extrauterine life. Scores between 4 and 6 usually require immediate
intervention such as suctioning or oxygen administration.
4. Which of the following interventions should the nurse include in the plan of care for a
newborn receiving phototherapy for hyperbilirubinemia? (Select all that apply)
A. Apply an opaque eye mask to the newborn
B. Apply lotion to the skin to prevent drying
C. Monitor the newborn’s temperature every 4 hours
D. Ensure the newborn is wearing only a diaper
E. Feed the newborn every 4 to 6 hours
F. Rotate the newborn every 2 to 3 hours
Correct Answer: A, C, D, F
Phototherapy requires maximum skin exposure, so only a diaper and eye protection
should be used to prevent retinal damage. The newborn is at risk for dehydration and
thermoregulation issues, requiring frequent temperature monitoring and feedings every 2
, to 3 hours. Repositioning the infant ensures that all skin surfaces are exposed to the light to
effectively break down bilirubin.
5. A nurse is preparing to administer Vitamin K (phytonadione) to a newborn. What is the
primary rationale for this medication?
A. To promote the synthesis of clotting factors
B. To prevent ophthalmia neonatorum
C. To stimulate the production of red blood cells
D. To enhance the immune system against sepsis
Correct Answer: A
Newborns are born with a sterile gut and lack the intestinal flora necessary to synthesize
Vitamin K. This deficiency leads to lower levels of clotting factors II, VII, IX, and X,
increasing the risk of Vitamin K deficiency bleeding (VKDB). A single intramuscular
injection of Vitamin K shortly after birth provides the necessary factors until the infant
starts producing it naturally.
6. A nurse is observing the fetal heart rate (FHR) monitor for a client in labor and notes late
decelerations. Which of the following actions should the nurse take first?
A. Assist the client into a side-lying position
B. Increase the rate of the oxytocin infusion
C. Perform a vaginal examination
