PNR 203/PNR203 Exam 2 V2 | Maternal-Newborn
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a client who is at 32 weeks of gestation and has a prescription for
magnesium sulfate IV to treat preeclampsia. Which of the following findings should the nurse
report to the provider as a sign of magnesium toxicity?
A. Blood pressure of 150/96 mm Hg
B. Respiratory rate of 16/min
C. Urinary output of 40 mL/hr
D. Absence of deep-tendon reflexes
Correct Answer: D
Explanation: The loss of deep-tendon reflexes is a primary clinical sign of magnesium
sulfate toxicity. Magnesium sulfate acts as a central nervous system depressant, and its
therapeutic range must be closely monitored. The nurse should also monitor for
respiratory depression and decreased urinary output as signs of toxicity.
2. A nurse is assessing a newborn who was born 2 hours ago. Which of the following findings
should the nurse report to the provider?
A. Acrocyanosis of the hands and feet
B. Generalized petechiae over the body
C. Overlapping cranial sutures
,D. Milia across the bridge of the nose
Correct Answer: B
Explanation: Generalized petechiae can indicate a serious condition such as a clotting
factor deficiency or infection and must be reported immediately. Acrocyanosis is a normal
finding in the first 24 to 48 hours of life. Overlapping sutures and milia are common, benign
findings in newborns.
3. A nurse is providing teaching to a client who is pregnant and has a new prescription for
iron supplements. Which of the following instructions should the nurse include?
A. Increase intake of high-fiber foods
B. Avoid taking the medication with orange juice
C. Take the medication with a glass of milk
D. Expect stools to become light clay-colored
Correct Answer: A
Explanation: Iron supplements frequently cause constipation, so increasing fiber and fluid
intake is essential for the client. Vitamin C, found in orange juice, actually enhances iron
absorption. Stools are expected to turn dark green or black, not light clay-colored, when
taking iron.
, 4. A nurse is assessing a client who is 1 day postpartum and is breastfeeding. The nurse notes
that the client’s fundus is firm, midline, and at the level of the umbilicus. Which of the
following actions should the nurse take?
A. Massage the fundus vigorously
B. Notify the provider of a potential hemorrhage
C. Document this as a normal finding
D. Assist the client to the bathroom to void
Correct Answer: C
Explanation: One day postpartum, the fundus should be firm and located approximately at
the level of the umbilicus. This indicates that normal uterine involution is occurring.
Vigorously massaging a firm fundus is unnecessary and can cause discomfort.
5. A nurse is performing a physical assessment of a newborn. Which of the following findings
should the nurse recognize as a manifestation of Down syndrome?
A. Low-set ears and a receding chin
B. Clinch fist with index finger overlapping the third
C. Transverse palmar crease
D. Polydactyly on the hands
Correct Answer: C
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a client who is at 32 weeks of gestation and has a prescription for
magnesium sulfate IV to treat preeclampsia. Which of the following findings should the nurse
report to the provider as a sign of magnesium toxicity?
A. Blood pressure of 150/96 mm Hg
B. Respiratory rate of 16/min
C. Urinary output of 40 mL/hr
D. Absence of deep-tendon reflexes
Correct Answer: D
Explanation: The loss of deep-tendon reflexes is a primary clinical sign of magnesium
sulfate toxicity. Magnesium sulfate acts as a central nervous system depressant, and its
therapeutic range must be closely monitored. The nurse should also monitor for
respiratory depression and decreased urinary output as signs of toxicity.
2. A nurse is assessing a newborn who was born 2 hours ago. Which of the following findings
should the nurse report to the provider?
A. Acrocyanosis of the hands and feet
B. Generalized petechiae over the body
C. Overlapping cranial sutures
,D. Milia across the bridge of the nose
Correct Answer: B
Explanation: Generalized petechiae can indicate a serious condition such as a clotting
factor deficiency or infection and must be reported immediately. Acrocyanosis is a normal
finding in the first 24 to 48 hours of life. Overlapping sutures and milia are common, benign
findings in newborns.
3. A nurse is providing teaching to a client who is pregnant and has a new prescription for
iron supplements. Which of the following instructions should the nurse include?
A. Increase intake of high-fiber foods
B. Avoid taking the medication with orange juice
C. Take the medication with a glass of milk
D. Expect stools to become light clay-colored
Correct Answer: A
Explanation: Iron supplements frequently cause constipation, so increasing fiber and fluid
intake is essential for the client. Vitamin C, found in orange juice, actually enhances iron
absorption. Stools are expected to turn dark green or black, not light clay-colored, when
taking iron.
, 4. A nurse is assessing a client who is 1 day postpartum and is breastfeeding. The nurse notes
that the client’s fundus is firm, midline, and at the level of the umbilicus. Which of the
following actions should the nurse take?
A. Massage the fundus vigorously
B. Notify the provider of a potential hemorrhage
C. Document this as a normal finding
D. Assist the client to the bathroom to void
Correct Answer: C
Explanation: One day postpartum, the fundus should be firm and located approximately at
the level of the umbilicus. This indicates that normal uterine involution is occurring.
Vigorously massaging a firm fundus is unnecessary and can cause discomfort.
5. A nurse is performing a physical assessment of a newborn. Which of the following findings
should the nurse recognize as a manifestation of Down syndrome?
A. Low-set ears and a receding chin
B. Clinch fist with index finger overlapping the third
C. Transverse palmar crease
D. Polydactyly on the hands
Correct Answer: C
