NUR 230 MATERNAL-NEWBORN NURSING
EXAM 2 COMPREHENSIVE PRACTICE
QUESTIONS AND ANSWERS LATEST UPDATE
Question 1
A client at 34 weeks gestation is admitted to the labor and delivery unit with a
diagnosis of severe preeclampsia. The nurse initiates an intravenous infusion of
magnesium sulfate. Which assessment finding requires immediate intervention
by the nurse?
A. Deep tendon reflexes of 1+
B. Urinary output of 45 mL over 2 hours
, C. Respiratory rate of 14 breaths/minute
D. Blood pressure of 150/95 mmHg
Answer: B. Urinary output of 45 mL over 2 hours
Explanation: Magnesium sulfate is excreted solely by the kidneys. A urinary
output of less than 30 mL/hour (45 mL over 2 hours is only 22.5 mL/hour)
indicates renal impairment, which can quickly lead to toxic accumulations of
magnesium. This requires immediate cessation of the infusion and
notification of the provider. Deep tendon reflexes of 1+ and a respiratory rate
of 14 are low-normal but not yet toxic indicators (toxicity occurs at
respiratory rates below 12 and absent reflexes). A blood pressure of 150/95
mmHg is expected in severe preeclampsia and managed concurrently.
Question 2
The nurse is interpreting a fetal heart rate (FHR) monitor strip for a client in
active labor. The nurse notes a baseline FHR of 140 beats/minute with
repeated decelerations that begin after the peak of the uterine contraction
and return to baseline well after the contraction has ended. Which is the
priority nursing action?
A. Perform a sterile vaginal examination to check for cord prolapse.
B. Change the client's position to a lateral side-lying position.
C. Administer oxygen via nasal cannula at 4 L/minute.
D. Prepare the client for immediate amniotomy.
, Answer: B. Change the client's position to a lateral side-lying position.
Explanation: The description matches late decelerations, which are caused by
uteroplacental insufficiency. The first step in intrauterine resuscitation is to
turn the client onto her side to relieve pressure on the vena cava and improve
placental blood flow. Oxygen should be delivered via a non-rebreather mask
at 8–10 L/minute, not via a nasal cannula at 4 L/minute. Vaginal exams are
indicated for variable decelerations to check for cord prolapse.
Question 3
A postpartum nurse is assessing a client 4 hours after a vaginal delivery of a 9
lb newborn. The nurse notes that the client’s fundus is boggy and located two
fingerbreadths above the umbilicus, deviated to the right. Which action should
the nurse take first?
A. Massage the fundus vigorously until firm.
B. Assist the client to the bathroom to void.
C. Notify the healthcare provider of a suspected hematoma.
D. Administer a prescribed intramuscular injection of methylergonovine.
Answer: B. Assist the client to the bathroom to void.
Explanation: A fundus that is elevated above the umbilicus and deviated to
the right indicates a distended bladder. A full bladder pushes the uterus out
of place and prevents it from contracting effectively, leading to uterine atony
and potential hemorrhage. Assisting the client to void resolves the
, displacement. Massaging a displaced uterus before emptying the bladder will
not permanently correct the bogginess.
Question 4
The nurse is performing a physical assessment on a 2-hour-old newborn. When
the nurse gently strokes the side of the infant's cheek, the newborn turns its
head toward that side and opens its mouth. The nurse correctly documents
this as which reflex?
A. Moro reflex
B. Sucking reflex
C. Rooting reflex
D. Tonic neck reflex
Answer: C. Rooting reflex
Explanation: The rooting reflex is elicited by stroking the newborn's cheek or
edge of the mouth. The infant should turn toward the side touched and open
the mouth to find the food source. The Moro reflex is a startle response to
loud noises or dropping sensations. Sucking occurs when an object is placed
in the mouth. Tonic neck occurs when the head is turned to one side and the
extremities on that side extend.
Question 5
EXAM 2 COMPREHENSIVE PRACTICE
QUESTIONS AND ANSWERS LATEST UPDATE
Question 1
A client at 34 weeks gestation is admitted to the labor and delivery unit with a
diagnosis of severe preeclampsia. The nurse initiates an intravenous infusion of
magnesium sulfate. Which assessment finding requires immediate intervention
by the nurse?
A. Deep tendon reflexes of 1+
B. Urinary output of 45 mL over 2 hours
, C. Respiratory rate of 14 breaths/minute
D. Blood pressure of 150/95 mmHg
Answer: B. Urinary output of 45 mL over 2 hours
Explanation: Magnesium sulfate is excreted solely by the kidneys. A urinary
output of less than 30 mL/hour (45 mL over 2 hours is only 22.5 mL/hour)
indicates renal impairment, which can quickly lead to toxic accumulations of
magnesium. This requires immediate cessation of the infusion and
notification of the provider. Deep tendon reflexes of 1+ and a respiratory rate
of 14 are low-normal but not yet toxic indicators (toxicity occurs at
respiratory rates below 12 and absent reflexes). A blood pressure of 150/95
mmHg is expected in severe preeclampsia and managed concurrently.
Question 2
The nurse is interpreting a fetal heart rate (FHR) monitor strip for a client in
active labor. The nurse notes a baseline FHR of 140 beats/minute with
repeated decelerations that begin after the peak of the uterine contraction
and return to baseline well after the contraction has ended. Which is the
priority nursing action?
A. Perform a sterile vaginal examination to check for cord prolapse.
B. Change the client's position to a lateral side-lying position.
C. Administer oxygen via nasal cannula at 4 L/minute.
D. Prepare the client for immediate amniotomy.
, Answer: B. Change the client's position to a lateral side-lying position.
Explanation: The description matches late decelerations, which are caused by
uteroplacental insufficiency. The first step in intrauterine resuscitation is to
turn the client onto her side to relieve pressure on the vena cava and improve
placental blood flow. Oxygen should be delivered via a non-rebreather mask
at 8–10 L/minute, not via a nasal cannula at 4 L/minute. Vaginal exams are
indicated for variable decelerations to check for cord prolapse.
Question 3
A postpartum nurse is assessing a client 4 hours after a vaginal delivery of a 9
lb newborn. The nurse notes that the client’s fundus is boggy and located two
fingerbreadths above the umbilicus, deviated to the right. Which action should
the nurse take first?
A. Massage the fundus vigorously until firm.
B. Assist the client to the bathroom to void.
C. Notify the healthcare provider of a suspected hematoma.
D. Administer a prescribed intramuscular injection of methylergonovine.
Answer: B. Assist the client to the bathroom to void.
Explanation: A fundus that is elevated above the umbilicus and deviated to
the right indicates a distended bladder. A full bladder pushes the uterus out
of place and prevents it from contracting effectively, leading to uterine atony
and potential hemorrhage. Assisting the client to void resolves the
, displacement. Massaging a displaced uterus before emptying the bladder will
not permanently correct the bogginess.
Question 4
The nurse is performing a physical assessment on a 2-hour-old newborn. When
the nurse gently strokes the side of the infant's cheek, the newborn turns its
head toward that side and opens its mouth. The nurse correctly documents
this as which reflex?
A. Moro reflex
B. Sucking reflex
C. Rooting reflex
D. Tonic neck reflex
Answer: C. Rooting reflex
Explanation: The rooting reflex is elicited by stroking the newborn's cheek or
edge of the mouth. The infant should turn toward the side touched and open
the mouth to find the food source. The Moro reflex is a startle response to
loud noises or dropping sensations. Sucking occurs when an object is placed
in the mouth. Tonic neck occurs when the head is turned to one side and the
extremities on that side extend.
Question 5
