NUR 202/NUR202 Exam 4 V1 | Maternal-Newborn
Nursing Q&A with Rationale | Fortis College
1. A nurse is assessing a client who is 34 weeks pregnant and has a prescription for
magnesium sulfate to treat preeclampsia. Which of the following findings should the nurse
identify as a priority to report to the provider?
A. Respiratory rate of 10/min
B. Urinary output of 40 mL/hr
C. Deep tendon reflexes of 2+
D. Occasional fetal movement
C. Occasional fetal movement
Correct Answer: A
Explanation: A respiratory rate of 10/min is a sign of magnesium toxicity, as the
therapeutic range usually maintains respirations above 12/min. Magnesium sulfate is a
central nervous system depressant that can lead to respiratory arrest if levels become too
high. The nurse must immediately stop the infusion and notify the provider while
preparing the antidote, calcium gluconate.
2. A nurse is caring for a client who is in active labor and has a suspected umbilical cord
prolapse. Which of the following actions should the nurse take first?
A. Administer oxygen via nonrebreather mask
,B. Increase the intravenous fluid infusion rate
C. Apply upward pressure to the presenting part with a sterile gloved hand
D. Prepare the client for an emergency cesarean birth
Correct Answer: C
Explanation: Applying upward pressure to the presenting part is the priority action
because it relieves compression on the umbilical cord, ensuring fetal oxygenation. Cord
prolapse is an obstetric emergency that requires immediate intervention to prevent fetal
hypoxia or death. While the other actions are necessary components of care, relieving the
mechanical obstruction is the most critical first step.
3. A client at 32 weeks of gestation is admitted with painless, bright red vaginal bleeding.
Which of the following diagnostic procedures should the nurse expect the provider to order?
A. Contraction stress test
B. Amniocentesis
C. Digital vaginal examination
D. Transvaginal ultrasound
Correct Answer: D
Explanation: Painless bright red bleeding is a classic sign of placenta previa, and an
ultrasound is used to confirm the position of the placenta. A digital vaginal exam is strictly
contraindicated until placenta previa is ruled out, as it can cause massive hemorrhage.
,Early diagnosis through imaging allows the healthcare team to plan for safe delivery and
monitor for maternal stability.
4. A nurse is monitoring a client who is receiving oxytocin for induction of labor. Which of the
following findings requires the nurse to discontinue the infusion?
A. Contraction duration of 60 seconds
B. Late decelerations observed on the fetal heart rate monitor
C. Five contractions occurring within a 10-minute period
D. Contraction frequency of every 3 minutes
Correct Answer: B
Explanation: Late decelerations are indicative of uteroplacental insufficiency and
represent a non-reassuring fetal heart rate pattern. The presence of late decelerations
requires immediate discontinuation of oxytocin to stop uterine stimulation and improve
fetal oxygenation. The nurse should also turn the client to a side-lying position and increase
IV fluids as part of intrauterine resuscitation.
5. A nurse is assessing a newborn who is 12 hours old and has a mother with type 1 diabetes
mellitus. The nurse should identify that which of the following findings is most concerning?
A. Axillary temperature of 36.8 C (98.2 F)
B. Heart rate of 140/min
C. Blood glucose level of 38 mg/dL
, D. Weight of 4,200 grams
Correct Answer: C
Explanation: A blood glucose level of 38 mg/dL is below the expected range for a newborn
and indicates hypoglycemia. Infants of diabetic mothers are at high risk for hypoglycemia
due to hyperinsulinism resulting from high maternal glucose levels in utero. The nurse
must initiate feeding or administer glucose per protocol to prevent neurological damage or
seizures in the neonate.
6. A nurse is providing teaching to a client who has a prescription for terbutaline to inhibit
preterm labor. Which of the following adverse effects should the nurse include in the
teaching?
A. Bradycardia
B. Hypokalemia
C. Hypoglycemia
D. Tachycardia
Correct Answer: D
Explanation: Terbutaline is a beta-adrenergic agonist that commonly causes maternal and
fetal tachycardia as a side effect. It works by relaxing smooth muscle, but its effects on the
cardiovascular system can lead to palpitations and chest pain. The nurse should monitor
the client’s heart rate and withhold the medication if the maternal heart rate exceeds
120/min.
Nursing Q&A with Rationale | Fortis College
1. A nurse is assessing a client who is 34 weeks pregnant and has a prescription for
magnesium sulfate to treat preeclampsia. Which of the following findings should the nurse
identify as a priority to report to the provider?
A. Respiratory rate of 10/min
B. Urinary output of 40 mL/hr
C. Deep tendon reflexes of 2+
D. Occasional fetal movement
C. Occasional fetal movement
Correct Answer: A
Explanation: A respiratory rate of 10/min is a sign of magnesium toxicity, as the
therapeutic range usually maintains respirations above 12/min. Magnesium sulfate is a
central nervous system depressant that can lead to respiratory arrest if levels become too
high. The nurse must immediately stop the infusion and notify the provider while
preparing the antidote, calcium gluconate.
2. A nurse is caring for a client who is in active labor and has a suspected umbilical cord
prolapse. Which of the following actions should the nurse take first?
A. Administer oxygen via nonrebreather mask
,B. Increase the intravenous fluid infusion rate
C. Apply upward pressure to the presenting part with a sterile gloved hand
D. Prepare the client for an emergency cesarean birth
Correct Answer: C
Explanation: Applying upward pressure to the presenting part is the priority action
because it relieves compression on the umbilical cord, ensuring fetal oxygenation. Cord
prolapse is an obstetric emergency that requires immediate intervention to prevent fetal
hypoxia or death. While the other actions are necessary components of care, relieving the
mechanical obstruction is the most critical first step.
3. A client at 32 weeks of gestation is admitted with painless, bright red vaginal bleeding.
Which of the following diagnostic procedures should the nurse expect the provider to order?
A. Contraction stress test
B. Amniocentesis
C. Digital vaginal examination
D. Transvaginal ultrasound
Correct Answer: D
Explanation: Painless bright red bleeding is a classic sign of placenta previa, and an
ultrasound is used to confirm the position of the placenta. A digital vaginal exam is strictly
contraindicated until placenta previa is ruled out, as it can cause massive hemorrhage.
,Early diagnosis through imaging allows the healthcare team to plan for safe delivery and
monitor for maternal stability.
4. A nurse is monitoring a client who is receiving oxytocin for induction of labor. Which of the
following findings requires the nurse to discontinue the infusion?
A. Contraction duration of 60 seconds
B. Late decelerations observed on the fetal heart rate monitor
C. Five contractions occurring within a 10-minute period
D. Contraction frequency of every 3 minutes
Correct Answer: B
Explanation: Late decelerations are indicative of uteroplacental insufficiency and
represent a non-reassuring fetal heart rate pattern. The presence of late decelerations
requires immediate discontinuation of oxytocin to stop uterine stimulation and improve
fetal oxygenation. The nurse should also turn the client to a side-lying position and increase
IV fluids as part of intrauterine resuscitation.
5. A nurse is assessing a newborn who is 12 hours old and has a mother with type 1 diabetes
mellitus. The nurse should identify that which of the following findings is most concerning?
A. Axillary temperature of 36.8 C (98.2 F)
B. Heart rate of 140/min
C. Blood glucose level of 38 mg/dL
, D. Weight of 4,200 grams
Correct Answer: C
Explanation: A blood glucose level of 38 mg/dL is below the expected range for a newborn
and indicates hypoglycemia. Infants of diabetic mothers are at high risk for hypoglycemia
due to hyperinsulinism resulting from high maternal glucose levels in utero. The nurse
must initiate feeding or administer glucose per protocol to prevent neurological damage or
seizures in the neonate.
6. A nurse is providing teaching to a client who has a prescription for terbutaline to inhibit
preterm labor. Which of the following adverse effects should the nurse include in the
teaching?
A. Bradycardia
B. Hypokalemia
C. Hypoglycemia
D. Tachycardia
Correct Answer: D
Explanation: Terbutaline is a beta-adrenergic agonist that commonly causes maternal and
fetal tachycardia as a side effect. It works by relaxing smooth muscle, but its effects on the
cardiovascular system can lead to palpitations and chest pain. The nurse should monitor
the client’s heart rate and withhold the medication if the maternal heart rate exceeds
120/min.
