NUR 202/NUR202 Exam 3 V2 | Maternal-Newborn
Nursing Q&A with Rationale | Fortis College
1. A nurse is assessing a client who is 2 hours postpartum and observes a heavy amount of
lochia rubra with several large clots. What is the priority nursing action?
A. Administer oxytocin 20 units IM immediately.
B. Assist the client to the bathroom to void.
C. Notify the healthcare provider of the findings.
D. Perform fundal massage to check for firmness.
Correct Answer: D
Explanation: The priority action for heavy bleeding and clots in the early postpartum
period is to assess the fundus for uterine atony and massage it if it is boggy. Massaging the
fundus stimulates uterine contractions, which compress bleeding vessels at the placental
site to reduce blood loss. This assessment is the most critical first step before moving to
pharmacological interventions or notification of providers.
2. A client at 34 weeks gestation is receiving magnesium sulfate for preeclampsia. Which
assessment finding indicates magnesium toxicity?
A. Deep tendon reflexes 2+ bilaterally.
B. Respiratory rate of 10 breaths per minute.
C. Urine output of 40 mL/hr.
,D. Blood pressure of 150/96 mmHg.
Correct Answer: B
Explanation: Magnesium sulfate is a CNS depressant, and a respiratory rate below 12
breaths per minute is a classic sign of toxicity. Other signs include loss of deep tendon
reflexes, decreased urine output, and cardiac arrest if the dose is high enough. The nurse
must immediately stop the infusion and prepare to administer calcium gluconate if toxicity
is suspected.
3. Which of the following signs should the nurse expect to find in a newborn diagnosed with
Neonatal Abstinence Syndrome (NAS)?
A. Hypotonia and lethargy.
B. Slow and shallow respirations.
C. Excessive sneezing and high-pitched cry.
D. Hypothermia and bradycardia.
Correct Answer: C
Explanation: Newborns experiencing withdrawal symptoms from intrauterine exposure to
opioids typically exhibit central nervous system irritability. Common symptoms include
excessive sneezing, tremors, hypertonia, and a shrill, high-pitched cry. These infants also
frequently suffer from gastrointestinal upset and feeding difficulties during the withdrawal
phase.
,4. A nurse is caring for a client with a history of gestational diabetes. Which risk factor should
the nurse monitor for in the newborn immediately following delivery?
A. Hyperglycemia.
B. Hypernatremia.
C. Hypoglycemia.
D. Hypercalcemia.
Correct Answer: C
Explanation: Infants of diabetic mothers are at high risk for hypoglycemia because they
produce high levels of insulin in response to the mother’s high glucose levels while in utero.
Once the umbilical cord is cut, the glucose supply is removed, but the infant’s pancreas
continues to produce excess insulin, leading to a rapid drop in blood sugar. Nurses should
perform heel sticks for glucose monitoring within the first hour of life.
5. A client at 38 weeks gestation is diagnosed with placenta previa and presents with painless
bright red vaginal bleeding. What is a contraindicated nursing action?
A. Initiating intravenous access.
B. Performing a vaginal examination.
C. Applying an external fetal monitor.
D. Obtaining a type and crossmatch for blood.
Correct Answer: B
, Explanation: In cases of placenta previa, the placenta is implanted over or near the
cervical os, and a vaginal examination can cause catastrophic hemorrhage. Standard
protocol dictates that no vaginal or rectal exams should be performed until the location of
the placenta is confirmed via ultrasound. Management focuses on maternal stabilization
and monitoring fetal well-being through external means.
6. The nurse is teaching a postpartum client about the use of a diaphragm for contraception.
Which statement by the client indicates a need for further teaching?
A. I will use oil-based lubricants to help insert the diaphragm.
B. I need to get resized for my diaphragm if I gain or lose 20 pounds.
C. I should leave the diaphragm in for at least 6 hours after intercourse.
D. I should inspect the diaphragm for holes or tears before each use.
Correct Answer: A
Explanation: Oil-based lubricants can weaken the latex of the diaphragm, leading to
degradation and potential failure. Water-soluble lubricants are recommended for use with
latex contraceptive devices. The client must also be aware of the need for resizing after
significant weight changes or pregnancy to ensure a proper fit.
7. A nurse is assessing a newborn and notes a bluish discoloration of the hands and feet while
the trunk is pink. How should the nurse document this finding?
A. Central cyanosis.
B. Harlequin sign.
Nursing Q&A with Rationale | Fortis College
1. A nurse is assessing a client who is 2 hours postpartum and observes a heavy amount of
lochia rubra with several large clots. What is the priority nursing action?
A. Administer oxytocin 20 units IM immediately.
B. Assist the client to the bathroom to void.
C. Notify the healthcare provider of the findings.
D. Perform fundal massage to check for firmness.
Correct Answer: D
Explanation: The priority action for heavy bleeding and clots in the early postpartum
period is to assess the fundus for uterine atony and massage it if it is boggy. Massaging the
fundus stimulates uterine contractions, which compress bleeding vessels at the placental
site to reduce blood loss. This assessment is the most critical first step before moving to
pharmacological interventions or notification of providers.
2. A client at 34 weeks gestation is receiving magnesium sulfate for preeclampsia. Which
assessment finding indicates magnesium toxicity?
A. Deep tendon reflexes 2+ bilaterally.
B. Respiratory rate of 10 breaths per minute.
C. Urine output of 40 mL/hr.
,D. Blood pressure of 150/96 mmHg.
Correct Answer: B
Explanation: Magnesium sulfate is a CNS depressant, and a respiratory rate below 12
breaths per minute is a classic sign of toxicity. Other signs include loss of deep tendon
reflexes, decreased urine output, and cardiac arrest if the dose is high enough. The nurse
must immediately stop the infusion and prepare to administer calcium gluconate if toxicity
is suspected.
3. Which of the following signs should the nurse expect to find in a newborn diagnosed with
Neonatal Abstinence Syndrome (NAS)?
A. Hypotonia and lethargy.
B. Slow and shallow respirations.
C. Excessive sneezing and high-pitched cry.
D. Hypothermia and bradycardia.
Correct Answer: C
Explanation: Newborns experiencing withdrawal symptoms from intrauterine exposure to
opioids typically exhibit central nervous system irritability. Common symptoms include
excessive sneezing, tremors, hypertonia, and a shrill, high-pitched cry. These infants also
frequently suffer from gastrointestinal upset and feeding difficulties during the withdrawal
phase.
,4. A nurse is caring for a client with a history of gestational diabetes. Which risk factor should
the nurse monitor for in the newborn immediately following delivery?
A. Hyperglycemia.
B. Hypernatremia.
C. Hypoglycemia.
D. Hypercalcemia.
Correct Answer: C
Explanation: Infants of diabetic mothers are at high risk for hypoglycemia because they
produce high levels of insulin in response to the mother’s high glucose levels while in utero.
Once the umbilical cord is cut, the glucose supply is removed, but the infant’s pancreas
continues to produce excess insulin, leading to a rapid drop in blood sugar. Nurses should
perform heel sticks for glucose monitoring within the first hour of life.
5. A client at 38 weeks gestation is diagnosed with placenta previa and presents with painless
bright red vaginal bleeding. What is a contraindicated nursing action?
A. Initiating intravenous access.
B. Performing a vaginal examination.
C. Applying an external fetal monitor.
D. Obtaining a type and crossmatch for blood.
Correct Answer: B
, Explanation: In cases of placenta previa, the placenta is implanted over or near the
cervical os, and a vaginal examination can cause catastrophic hemorrhage. Standard
protocol dictates that no vaginal or rectal exams should be performed until the location of
the placenta is confirmed via ultrasound. Management focuses on maternal stabilization
and monitoring fetal well-being through external means.
6. The nurse is teaching a postpartum client about the use of a diaphragm for contraception.
Which statement by the client indicates a need for further teaching?
A. I will use oil-based lubricants to help insert the diaphragm.
B. I need to get resized for my diaphragm if I gain or lose 20 pounds.
C. I should leave the diaphragm in for at least 6 hours after intercourse.
D. I should inspect the diaphragm for holes or tears before each use.
Correct Answer: A
Explanation: Oil-based lubricants can weaken the latex of the diaphragm, leading to
degradation and potential failure. Water-soluble lubricants are recommended for use with
latex contraceptive devices. The client must also be aware of the need for resizing after
significant weight changes or pregnancy to ensure a proper fit.
7. A nurse is assessing a newborn and notes a bluish discoloration of the hands and feet while
the trunk is pink. How should the nurse document this finding?
A. Central cyanosis.
B. Harlequin sign.
