PNR 203/PNR203 Exam 3 V1 | Maternal-Newborn
Nursing Q&A with Rationale | Fortis College
1. A nurse is monitoring a client who is receiving magnesium sulfate for preeclampsia. Which
of the following findings should the nurse identify as a sign of magnesium toxicity?
A. Hyperreflexia
B. Absence of deep tendon reflexes
C. Increased respiratory rate
D. Increased urinary output
Correct Answer: B
Explanation: Magnesium sulfate acts as a central nervous system depressant to prevent
seizures in preeclamptic patients. The loss of deep tendon reflexes (DTRs) is a primary
clinical indicator of magnesium toxicity. The nurse must immediately notify the provider
and potentially prepare the antidote, calcium gluconate.
2. A nurse is caring for a client in the first stage of labor and notices late decelerations on the
fetal heart rate monitor. Which of the following actions should the nurse take first?
A. Increase the oxytocin infusion rate
B. Assist the client into a side-lying position
C. Administer a narcotic analgesic
D. Prepare for an immediate amniotomy
,Correct Answer: B
Explanation: Late decelerations are indicative of uteroplacental insufficiency, which can
lead to fetal hypoxia. Repositioning the client to the left lateral position helps improve
placental perfusion by relieving pressure on the vena cava. This intervention is the priority
before other measures like increasing IV fluids or providing oxygen.
3. A client at 34 weeks gestation presents with sudden, sharp abdominal pain and a board-
like abdomen. The nurse should suspect which of the following conditions?
A. Placenta previa
B. Preterm labor
C. Placental abruption
D. Hydatidiform mole
Correct Answer: C
Explanation: Placental abruption is the premature separation of the placenta from the
uterine wall. It typically presents with intense uterine pain and abdominal rigidity. Unlike
placenta previa, which is characterized by painless bleeding, abruption is a surgical
emergency.
4. A nurse is assessing a postpartum client 2 hours after delivery and finds the fundus is boggy
and displaced to the right. Which of the following actions should the nurse take?
A. Administer oxytocin immediately
B. Perform a vigorous fundal massage
, C. Assist the client to the bathroom to void
D. Place the client in the Trendelenburg position
Correct Answer: C
Explanation: A displaced fundus to the right is usually caused by a full bladder, which
prevents the uterus from contracting effectively. Assisting the client to empty her bladder
will allow the uterus to return to the midline and contract. If the fundus remains boggy
after voiding, massage and medications may be indicated.
5. Which of the following medications should the nurse expect to administer to a newborn
within 1 hour of birth to prevent ophthalmia neonatorum?
A. Erythromycin ophthalmic ointment
B. Hepatitis B vaccine
C. Vitamin K
D. Gentamicin drops
Correct Answer: A
Explanation: Erythromycin ointment is legally mandated in many regions to prevent
neonatal blindness caused by gonorrhea or chlamydia. The medication is applied to the
conjunctival sac of each eye. This prophylaxis is standard care for all newborns regardless
of the mother’s infection status.
Nursing Q&A with Rationale | Fortis College
1. A nurse is monitoring a client who is receiving magnesium sulfate for preeclampsia. Which
of the following findings should the nurse identify as a sign of magnesium toxicity?
A. Hyperreflexia
B. Absence of deep tendon reflexes
C. Increased respiratory rate
D. Increased urinary output
Correct Answer: B
Explanation: Magnesium sulfate acts as a central nervous system depressant to prevent
seizures in preeclamptic patients. The loss of deep tendon reflexes (DTRs) is a primary
clinical indicator of magnesium toxicity. The nurse must immediately notify the provider
and potentially prepare the antidote, calcium gluconate.
2. A nurse is caring for a client in the first stage of labor and notices late decelerations on the
fetal heart rate monitor. Which of the following actions should the nurse take first?
A. Increase the oxytocin infusion rate
B. Assist the client into a side-lying position
C. Administer a narcotic analgesic
D. Prepare for an immediate amniotomy
,Correct Answer: B
Explanation: Late decelerations are indicative of uteroplacental insufficiency, which can
lead to fetal hypoxia. Repositioning the client to the left lateral position helps improve
placental perfusion by relieving pressure on the vena cava. This intervention is the priority
before other measures like increasing IV fluids or providing oxygen.
3. A client at 34 weeks gestation presents with sudden, sharp abdominal pain and a board-
like abdomen. The nurse should suspect which of the following conditions?
A. Placenta previa
B. Preterm labor
C. Placental abruption
D. Hydatidiform mole
Correct Answer: C
Explanation: Placental abruption is the premature separation of the placenta from the
uterine wall. It typically presents with intense uterine pain and abdominal rigidity. Unlike
placenta previa, which is characterized by painless bleeding, abruption is a surgical
emergency.
4. A nurse is assessing a postpartum client 2 hours after delivery and finds the fundus is boggy
and displaced to the right. Which of the following actions should the nurse take?
A. Administer oxytocin immediately
B. Perform a vigorous fundal massage
, C. Assist the client to the bathroom to void
D. Place the client in the Trendelenburg position
Correct Answer: C
Explanation: A displaced fundus to the right is usually caused by a full bladder, which
prevents the uterus from contracting effectively. Assisting the client to empty her bladder
will allow the uterus to return to the midline and contract. If the fundus remains boggy
after voiding, massage and medications may be indicated.
5. Which of the following medications should the nurse expect to administer to a newborn
within 1 hour of birth to prevent ophthalmia neonatorum?
A. Erythromycin ophthalmic ointment
B. Hepatitis B vaccine
C. Vitamin K
D. Gentamicin drops
Correct Answer: A
Explanation: Erythromycin ointment is legally mandated in many regions to prevent
neonatal blindness caused by gonorrhea or chlamydia. The medication is applied to the
conjunctival sac of each eye. This prophylaxis is standard care for all newborns regardless
of the mother’s infection status.
