PNR 203/PNR203 Exam 3 V2 | Maternal-Newborn
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a client who is at 36 weeks of gestation and has preeclampsia. Which
of the following findings should the nurse report to the provider as a sign of magnesium
sulfate toxicity?
A. Deep tendon reflexes of 2+
B. Respiratory rate of 10/min
C. Urine output of 40 mL/hr
D. Blood pressure of 150/95 mmHg
Correct Answer: B
Explanation: A respiratory rate of less than 12/min is a primary indicator of magnesium
sulfate toxicity. The nurse should immediately stop the infusion and notify the healthcare
provider to prevent respiratory arrest. Calcium gluconate should be readily available as the
antidote for magnesium toxicity.
2. A nurse is assessing a newborn 1 hour after birth. Which of the following findings should
the nurse report to the provider?
A. Generalized petechiae
B. Acrocyanosis
C. Heart rate of 140/min
,D. Respiratory rate of 45/min
Correct Answer: A
Explanation: Generalized petechiae can indicate a clotting factor deficiency or infection
and must be reported immediately. Acrocyanosis is a normal finding in the first 24 to 48
hours after birth. Normal newborn heart rates range from 110 to 160/min, and respiratory
rates range from 30 to 60/min.
3. A client at 38 weeks gestation is admitted with painless, bright red vaginal bleeding. Which
action should the nurse avoid?
A. Assessing fetal heart tones
B. Administering IV fluids
C. Obtaining a hemoglobin level
D. Performing a vaginal examination
Correct Answer: D
Explanation: Painless bright red bleeding is indicative of placenta previa, where the
placenta covers the cervical os. Performing a vaginal exam could cause severe hemorrhage
by puncturing the placenta. Management focuses on fetal monitoring and preparing for a
potential cesarean birth.
4. The nurse is providing discharge teaching to a mother who is breastfeeding. Which
statement indicates the mother understands the teaching regarding mastitis?
A. I should stop breastfeeding if my breast becomes red and painful.
, B. I should continue to breastfeed frequently on both breasts.
C. I need to wear a tight-fitting bra to prevent milk stasis.
D. I will limit my fluid intake to decrease breast engorgement.
Correct Answer: B
Explanation: Continuing to breastfeed or pump is essential to prevent milk stasis, which
contributes to mastitis. The mother should also be encouraged to increase fluid intake and
rest. Antibiotics are typically prescribed, and the milk remains safe for the infant during
treatment.
5. A nurse is assessing a client 2 hours postpartum. The fundus is boggy and displaced to the
right. Which action should the nurse take first?
A. Assist the client to void
B. Massage the fundus until firm
C. Administer oxytocin IV
D. Notify the provider
Correct Answer: A
Explanation: A displaced fundus to the right usually indicates a full bladder, which
prevents the uterus from contracting effectively. Emptying the bladder allows the uterus to
return to the midline and contract. If the fundus remains boggy after voiding, the nurse
should then perform fundal massage.
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a client who is at 36 weeks of gestation and has preeclampsia. Which
of the following findings should the nurse report to the provider as a sign of magnesium
sulfate toxicity?
A. Deep tendon reflexes of 2+
B. Respiratory rate of 10/min
C. Urine output of 40 mL/hr
D. Blood pressure of 150/95 mmHg
Correct Answer: B
Explanation: A respiratory rate of less than 12/min is a primary indicator of magnesium
sulfate toxicity. The nurse should immediately stop the infusion and notify the healthcare
provider to prevent respiratory arrest. Calcium gluconate should be readily available as the
antidote for magnesium toxicity.
2. A nurse is assessing a newborn 1 hour after birth. Which of the following findings should
the nurse report to the provider?
A. Generalized petechiae
B. Acrocyanosis
C. Heart rate of 140/min
,D. Respiratory rate of 45/min
Correct Answer: A
Explanation: Generalized petechiae can indicate a clotting factor deficiency or infection
and must be reported immediately. Acrocyanosis is a normal finding in the first 24 to 48
hours after birth. Normal newborn heart rates range from 110 to 160/min, and respiratory
rates range from 30 to 60/min.
3. A client at 38 weeks gestation is admitted with painless, bright red vaginal bleeding. Which
action should the nurse avoid?
A. Assessing fetal heart tones
B. Administering IV fluids
C. Obtaining a hemoglobin level
D. Performing a vaginal examination
Correct Answer: D
Explanation: Painless bright red bleeding is indicative of placenta previa, where the
placenta covers the cervical os. Performing a vaginal exam could cause severe hemorrhage
by puncturing the placenta. Management focuses on fetal monitoring and preparing for a
potential cesarean birth.
4. The nurse is providing discharge teaching to a mother who is breastfeeding. Which
statement indicates the mother understands the teaching regarding mastitis?
A. I should stop breastfeeding if my breast becomes red and painful.
, B. I should continue to breastfeed frequently on both breasts.
C. I need to wear a tight-fitting bra to prevent milk stasis.
D. I will limit my fluid intake to decrease breast engorgement.
Correct Answer: B
Explanation: Continuing to breastfeed or pump is essential to prevent milk stasis, which
contributes to mastitis. The mother should also be encouraged to increase fluid intake and
rest. Antibiotics are typically prescribed, and the milk remains safe for the infant during
treatment.
5. A nurse is assessing a client 2 hours postpartum. The fundus is boggy and displaced to the
right. Which action should the nurse take first?
A. Assist the client to void
B. Massage the fundus until firm
C. Administer oxytocin IV
D. Notify the provider
Correct Answer: A
Explanation: A displaced fundus to the right usually indicates a full bladder, which
prevents the uterus from contracting effectively. Emptying the bladder allows the uterus to
return to the midline and contract. If the fundus remains boggy after voiding, the nurse
should then perform fundal massage.
