PNR 203/PNR203 Exam 3 V3 | Maternal-Newborn
Nursing Q&A with Rationale | Fortis College
1. A nurse is assessing a newborn at 1 minute after birth. The heart rate is 110/min,
respiratory effort is slow and irregular, there is some flexion of the extremities, a grimace is
noted when stimulated, and the body is pink with blue extremities. What is the assigned
APGAR score?
A. 4
B. 6
C. 8
D. 5
Correct Answer: B
Explanation: The APGAR score is calculated based on five criteria including heart rate,
respiratory effort, muscle tone, reflex irritability, and color. In this scenario, the heart rate
(>100) earns 2 points, respiratory effort (slow/irregular) earns 1 point, muscle tone (some
flexion) earns 1 point, reflex irritability (grimace) earns 1 point, and color (acrocyanosis)
earns 1 point. This results in a total score of 6, which indicates that the newborn is having
some difficulty adjusting to extrauterine life and requires close monitoring.
2. A nurse is caring for a client in the first stage of labor and notes late decelerations on the
fetal heart rate monitor. Which of the following actions should the nurse take first?
A. Change the client’s position to a side-lying position.
,B. Increase the rate of the IV fluid infusion.
C. Administer oxygen via non-rebreather mask.
D. Notify the healthcare provider immediately.
Correct Answer: A
Explanation: Late decelerations are indicative of uteroplacental insufficiency and require
immediate nursing intervention to improve oxygenation to the fetus. The priority action is
to reposition the client to a lateral side-lying position to displace the uterus from the
inferior vena cava and improve blood flow. After repositioning, the nurse should then
proceed with oxygen administration, increasing IV fluids, and notifying the provider if the
pattern persists.
3. A postpartum client who is 4 hours post-delivery has a fundus that is firm, two
fingerbreadths above the umbilicus, and deviated to the right. Which of the following is the
most likely cause?
A. Uterine atony
B. Retained placental fragments
C. Bladder distention
D. Normal physiological transition
Correct Answer: C
,Explanation: A fundus that is displaced upward and to the right is a classic sign of bladder
distention. A full bladder prevents the uterus from contracting effectively and pushes it out
of the midline position. The nurse should encourage the client to void or perform
catheterization if necessary to prevent potential postpartum hemorrhage caused by uterine
atony secondary to a full bladder.
4. A nurse is monitoring a client receiving Magnesium Sulfate for preeclampsia. Which finding
should the nurse report to the provider as a sign of magnesium toxicity?
A. Deep tendon reflexes of 2+
B. Increased fetal heart rate variability
C. Urinary output of 40 mL per hour
D. Respiratory rate of 10 breaths per minute
Correct Answer: D
Explanation: Magnesium sulfate is a central nervous system depressant used to prevent
seizures in preeclamptic patients. A respiratory rate below 12 breaths per minute is a
primary sign of magnesium toxicity and requires immediate cessation of the infusion. Other
signs include loss of deep tendon reflexes and a significant drop in urinary output, both of
which must be monitored strictly during therapy.
5. A nurse is teaching a group of expectant parents about the ‘back to sleep’ campaign. Which
of the following statements by a parent indicates an understanding of the teaching?
A. I will place my baby on their side to prevent choking.
, B. I will use a soft mattress to keep the baby comfortable.
C. I will place my baby on their back when they go to sleep.
D. I will put a small pillow in the crib to support the baby’s head.
Correct Answer: C
Explanation: The ‘back to sleep’ campaign is a critical public health initiative designed to
reduce the risk of Sudden Infant Death Syndrome (SIDS). Infants should always be placed
on their backs on a firm, flat surface for every sleep period. Using soft bedding, pillows, or
side-lying positions significantly increases the risk of suffocation or SIDS and should be
avoided.
6. Which of the following medications is administered to a newborn within 1 to 2 hours of
birth to prevent ophthalmia neonatorum?
A. Erythromycin ophthalmic ointment
B. Hepatitis B vaccine
C. Vitamin K (Phytonadione)
D. Gentamicin sulfate
Correct Answer: A
Explanation: Erythromycin ophthalmic ointment is legally required in many jurisdictions
to prevent neonatal conjunctivitis (ophthalmia neonatorum) caused by Neisseria
gonorrhoeae or Chlamydia trachomatis. It is applied to the lower conjunctival sac of each
Nursing Q&A with Rationale | Fortis College
1. A nurse is assessing a newborn at 1 minute after birth. The heart rate is 110/min,
respiratory effort is slow and irregular, there is some flexion of the extremities, a grimace is
noted when stimulated, and the body is pink with blue extremities. What is the assigned
APGAR score?
A. 4
B. 6
C. 8
D. 5
Correct Answer: B
Explanation: The APGAR score is calculated based on five criteria including heart rate,
respiratory effort, muscle tone, reflex irritability, and color. In this scenario, the heart rate
(>100) earns 2 points, respiratory effort (slow/irregular) earns 1 point, muscle tone (some
flexion) earns 1 point, reflex irritability (grimace) earns 1 point, and color (acrocyanosis)
earns 1 point. This results in a total score of 6, which indicates that the newborn is having
some difficulty adjusting to extrauterine life and requires close monitoring.
2. A nurse is caring for a client in the first stage of labor and notes late decelerations on the
fetal heart rate monitor. Which of the following actions should the nurse take first?
A. Change the client’s position to a side-lying position.
,B. Increase the rate of the IV fluid infusion.
C. Administer oxygen via non-rebreather mask.
D. Notify the healthcare provider immediately.
Correct Answer: A
Explanation: Late decelerations are indicative of uteroplacental insufficiency and require
immediate nursing intervention to improve oxygenation to the fetus. The priority action is
to reposition the client to a lateral side-lying position to displace the uterus from the
inferior vena cava and improve blood flow. After repositioning, the nurse should then
proceed with oxygen administration, increasing IV fluids, and notifying the provider if the
pattern persists.
3. A postpartum client who is 4 hours post-delivery has a fundus that is firm, two
fingerbreadths above the umbilicus, and deviated to the right. Which of the following is the
most likely cause?
A. Uterine atony
B. Retained placental fragments
C. Bladder distention
D. Normal physiological transition
Correct Answer: C
,Explanation: A fundus that is displaced upward and to the right is a classic sign of bladder
distention. A full bladder prevents the uterus from contracting effectively and pushes it out
of the midline position. The nurse should encourage the client to void or perform
catheterization if necessary to prevent potential postpartum hemorrhage caused by uterine
atony secondary to a full bladder.
4. A nurse is monitoring a client receiving Magnesium Sulfate for preeclampsia. Which finding
should the nurse report to the provider as a sign of magnesium toxicity?
A. Deep tendon reflexes of 2+
B. Increased fetal heart rate variability
C. Urinary output of 40 mL per hour
D. Respiratory rate of 10 breaths per minute
Correct Answer: D
Explanation: Magnesium sulfate is a central nervous system depressant used to prevent
seizures in preeclamptic patients. A respiratory rate below 12 breaths per minute is a
primary sign of magnesium toxicity and requires immediate cessation of the infusion. Other
signs include loss of deep tendon reflexes and a significant drop in urinary output, both of
which must be monitored strictly during therapy.
5. A nurse is teaching a group of expectant parents about the ‘back to sleep’ campaign. Which
of the following statements by a parent indicates an understanding of the teaching?
A. I will place my baby on their side to prevent choking.
, B. I will use a soft mattress to keep the baby comfortable.
C. I will place my baby on their back when they go to sleep.
D. I will put a small pillow in the crib to support the baby’s head.
Correct Answer: C
Explanation: The ‘back to sleep’ campaign is a critical public health initiative designed to
reduce the risk of Sudden Infant Death Syndrome (SIDS). Infants should always be placed
on their backs on a firm, flat surface for every sleep period. Using soft bedding, pillows, or
side-lying positions significantly increases the risk of suffocation or SIDS and should be
avoided.
6. Which of the following medications is administered to a newborn within 1 to 2 hours of
birth to prevent ophthalmia neonatorum?
A. Erythromycin ophthalmic ointment
B. Hepatitis B vaccine
C. Vitamin K (Phytonadione)
D. Gentamicin sulfate
Correct Answer: A
Explanation: Erythromycin ophthalmic ointment is legally required in many jurisdictions
to prevent neonatal conjunctivitis (ophthalmia neonatorum) caused by Neisseria
gonorrhoeae or Chlamydia trachomatis. It is applied to the lower conjunctival sac of each
