PNR 203/PNR203 Exam 4 V1 | Maternal-Newborn
Nursing Q&A with Rationale | Fortis College
1. A nurse is assessing a postpartum client 2 hours after delivery and notes that the fundus is
boggy and displaced to the right. Which of the following actions should the nurse take first?
A. Administer oxytocin via intravenous infusion.
B. Notify the healthcare provider immediately.
C. Massage the fundus until it is firm.
D. Assist the client to the bathroom to void.
Correct Answer: D
Explanation: A displaced fundus to the right is a classic sign of bladder distention, which
prevents the uterus from contracting effectively. Assisting the client to empty their bladder
will allow the uterus to return to the midline and contract. Massaging is important, but if
the bladder is full, the uterus will not stay firm, and voiding addresses the root cause of
displacement.
2. A newborn is being assessed at 1 minute of life. The heart rate is 110/min, the baby has a
weak cry, some flexion of the extremities, grimaces when stimulated, and the body is pink
with blue extremities. What is the APGAR score?
A. 5
B. 8
,C. 7
D. 6
Correct Answer: D
Explanation: The score is calculated as follows: Heart rate > 100 (2 points), weak cry (1
point), some flexion (1 point), grimace (1 point), and acrocyanosis (1 point), totaling 6. An
APGAR score of 6 indicates moderate distress and may require interventions like
stimulation or oxygen. The assessment must be repeated at 5 minutes to determine the
infant’s response to the transition to extrauterine life.
3. A nurse is caring for a client receiving magnesium sulfate for preeclampsia. The nurse notes
a respiratory rate of 10/min and absent deep tendon reflexes. Which medication should the
nurse prepare to administer?
A. Naloxone
B. Calcium gluconate
C. Terbutaline
D. Hydralazine
Correct Answer: B
Explanation: Calcium gluconate is the specific antidote for magnesium sulfate toxicity.
Signs of toxicity include decreased respirations, loss of deep tendon reflexes, and oliguria.
The nurse must stop the infusion immediately and prepare the antidote to prevent
respiratory or cardiac arrest.
, 4. A nurse is providing discharge teaching to the parents of a newborn who just underwent a
circumcision. Which of the following instructions should be included?
A. Apply diaper loosely to prevent friction on the site.
B. Wash the area with soap and water at every diaper change.
C. Pull off the yellow crust if it forms to prevent infection.
D. Clean the area with alcohol wipes to promote drying.
Correct Answer: A
Explanation: Applying the diaper loosely prevents pressure and irritation on the surgical
site during the healing process. Parents should be taught that a yellow exudate or crust is a
normal part of healing and should not be removed. Cleaning should be done with warm
water only, avoiding soap or alcohol which can cause pain and skin breakdown.
5. Which of the following is a characteristic finding of a newborn born to a mother with
gestational diabetes?
A. Hyperglycemia
B. Macrosomia
C. Intrauterine growth restriction
D. Hypercalcemia
Correct Answer: B
Nursing Q&A with Rationale | Fortis College
1. A nurse is assessing a postpartum client 2 hours after delivery and notes that the fundus is
boggy and displaced to the right. Which of the following actions should the nurse take first?
A. Administer oxytocin via intravenous infusion.
B. Notify the healthcare provider immediately.
C. Massage the fundus until it is firm.
D. Assist the client to the bathroom to void.
Correct Answer: D
Explanation: A displaced fundus to the right is a classic sign of bladder distention, which
prevents the uterus from contracting effectively. Assisting the client to empty their bladder
will allow the uterus to return to the midline and contract. Massaging is important, but if
the bladder is full, the uterus will not stay firm, and voiding addresses the root cause of
displacement.
2. A newborn is being assessed at 1 minute of life. The heart rate is 110/min, the baby has a
weak cry, some flexion of the extremities, grimaces when stimulated, and the body is pink
with blue extremities. What is the APGAR score?
A. 5
B. 8
,C. 7
D. 6
Correct Answer: D
Explanation: The score is calculated as follows: Heart rate > 100 (2 points), weak cry (1
point), some flexion (1 point), grimace (1 point), and acrocyanosis (1 point), totaling 6. An
APGAR score of 6 indicates moderate distress and may require interventions like
stimulation or oxygen. The assessment must be repeated at 5 minutes to determine the
infant’s response to the transition to extrauterine life.
3. A nurse is caring for a client receiving magnesium sulfate for preeclampsia. The nurse notes
a respiratory rate of 10/min and absent deep tendon reflexes. Which medication should the
nurse prepare to administer?
A. Naloxone
B. Calcium gluconate
C. Terbutaline
D. Hydralazine
Correct Answer: B
Explanation: Calcium gluconate is the specific antidote for magnesium sulfate toxicity.
Signs of toxicity include decreased respirations, loss of deep tendon reflexes, and oliguria.
The nurse must stop the infusion immediately and prepare the antidote to prevent
respiratory or cardiac arrest.
, 4. A nurse is providing discharge teaching to the parents of a newborn who just underwent a
circumcision. Which of the following instructions should be included?
A. Apply diaper loosely to prevent friction on the site.
B. Wash the area with soap and water at every diaper change.
C. Pull off the yellow crust if it forms to prevent infection.
D. Clean the area with alcohol wipes to promote drying.
Correct Answer: A
Explanation: Applying the diaper loosely prevents pressure and irritation on the surgical
site during the healing process. Parents should be taught that a yellow exudate or crust is a
normal part of healing and should not be removed. Cleaning should be done with warm
water only, avoiding soap or alcohol which can cause pain and skin breakdown.
5. Which of the following is a characteristic finding of a newborn born to a mother with
gestational diabetes?
A. Hyperglycemia
B. Macrosomia
C. Intrauterine growth restriction
D. Hypercalcemia
Correct Answer: B
