PNR 203/PNR203 Exam 4 V2 | Maternal-Newborn
Nursing Q&A with Rationale | Fortis College
1. A nurse is assessing a client 2 hours postpartum and notes the fundus is boggy and
displaced to the right. What is the priority nursing intervention?
A. Administer oxytocin as ordered.
B. Perform a fundal massage.
C. Assist the client to the bathroom to void.
D. Notify the healthcare provider immediately.
Correct Answer: C
Explanation: A displaced fundus to the right usually indicates a distended bladder, which
prevents the uterus from contracting effectively. Assisting the client to void is the priority
to allow the uterus to return to the midline and contract. While fundal massage is
important for a boggy uterus, the displacement indicates the bladder must be emptied first
to resolve the underlying cause.
2. When assessing a newborn with a suspected diagnosis of Respiratory Distress Syndrome
(RDS), which clinical manifestation should the nurse expect to find?
A. Acrocyanosis
B. Diaphragmatic breathing
C. Respiratory rate of 45 breaths/min
,D. Nasal flaring and grunting
Correct Answer: D
Explanation: Nasal flaring, expiratory grunting, and intercostal retractions are classic
signs of respiratory distress in the neonate. Acrocyanosis is a normal finding in the first 24
hours of life and does not indicate RDS. A respiratory rate of 45 is within the normal range
of 30-60 breaths per minute for a newborn.
3. A nurse is monitoring a client receiving Magnesium Sulfate for preeclampsia. Which
assessment finding would indicate magnesium toxicity?
A. Urinary output of 40 mL/hr
B. Blood pressure of 150/90 mmHg
C. Absence of deep tendon reflexes
D. Increased respiratory rate
Correct Answer: C
Explanation: The loss of deep tendon reflexes is one of the earliest signs of magnesium
sulfate toxicity. Other signs include respiratory depression (less than 12 breaths/min) and
a significant drop in urinary output. Magnesium sulfate is a central nervous system
depressant used to prevent seizures, but levels must be monitored closely to prevent toxic
accumulation.
, 4. Which of the following medications is routinely administered to a newborn within 1 hour
of birth to prevent ophthalmia neonatorum?
A. Vitamin K (Phytonadione)
B. Hepatitis B Vaccine
C. Erythromycin ophthalmic ointment
D. Nystatin
Correct Answer: C
Explanation: Erythromycin ophthalmic ointment is used as a prophylactic treatment to
prevent blindness caused by Neisseria gonorrhoeae or Chlamydia trachomatis acquired
during birth. It is a legal requirement in most states to administer this within the first hour
of life. Vitamin K is given to prevent hemorrhagic disease, not eye infections.
5. A postpartum client who is breastfeeding complains of nipple soreness. Which intervention
should the nurse recommend?
A. Apply alcohol-based wipes to the nipples after feeding.
B. Wash the nipples with soap and water daily.
C. Use a nipple shield for every feeding session.
D. Apply a small amount of breast milk to the nipples after feeding.
Correct Answer: D
Nursing Q&A with Rationale | Fortis College
1. A nurse is assessing a client 2 hours postpartum and notes the fundus is boggy and
displaced to the right. What is the priority nursing intervention?
A. Administer oxytocin as ordered.
B. Perform a fundal massage.
C. Assist the client to the bathroom to void.
D. Notify the healthcare provider immediately.
Correct Answer: C
Explanation: A displaced fundus to the right usually indicates a distended bladder, which
prevents the uterus from contracting effectively. Assisting the client to void is the priority
to allow the uterus to return to the midline and contract. While fundal massage is
important for a boggy uterus, the displacement indicates the bladder must be emptied first
to resolve the underlying cause.
2. When assessing a newborn with a suspected diagnosis of Respiratory Distress Syndrome
(RDS), which clinical manifestation should the nurse expect to find?
A. Acrocyanosis
B. Diaphragmatic breathing
C. Respiratory rate of 45 breaths/min
,D. Nasal flaring and grunting
Correct Answer: D
Explanation: Nasal flaring, expiratory grunting, and intercostal retractions are classic
signs of respiratory distress in the neonate. Acrocyanosis is a normal finding in the first 24
hours of life and does not indicate RDS. A respiratory rate of 45 is within the normal range
of 30-60 breaths per minute for a newborn.
3. A nurse is monitoring a client receiving Magnesium Sulfate for preeclampsia. Which
assessment finding would indicate magnesium toxicity?
A. Urinary output of 40 mL/hr
B. Blood pressure of 150/90 mmHg
C. Absence of deep tendon reflexes
D. Increased respiratory rate
Correct Answer: C
Explanation: The loss of deep tendon reflexes is one of the earliest signs of magnesium
sulfate toxicity. Other signs include respiratory depression (less than 12 breaths/min) and
a significant drop in urinary output. Magnesium sulfate is a central nervous system
depressant used to prevent seizures, but levels must be monitored closely to prevent toxic
accumulation.
, 4. Which of the following medications is routinely administered to a newborn within 1 hour
of birth to prevent ophthalmia neonatorum?
A. Vitamin K (Phytonadione)
B. Hepatitis B Vaccine
C. Erythromycin ophthalmic ointment
D. Nystatin
Correct Answer: C
Explanation: Erythromycin ophthalmic ointment is used as a prophylactic treatment to
prevent blindness caused by Neisseria gonorrhoeae or Chlamydia trachomatis acquired
during birth. It is a legal requirement in most states to administer this within the first hour
of life. Vitamin K is given to prevent hemorrhagic disease, not eye infections.
5. A postpartum client who is breastfeeding complains of nipple soreness. Which intervention
should the nurse recommend?
A. Apply alcohol-based wipes to the nipples after feeding.
B. Wash the nipples with soap and water daily.
C. Use a nipple shield for every feeding session.
D. Apply a small amount of breast milk to the nipples after feeding.
Correct Answer: D
