NUR 202/NUR202 Exam 2 V1 | Maternal-Newborn
Nursing Q&A with Rationale | Fortis College
1. A nurse is assessing a client in the first stage of labor and notes the presence of early
decelerations on the fetal monitor. Which action should the nurse take next?
A. Prepare for an emergency cesarean section.
B. Increase the rate of the primary intravenous infusion.
C. Continue to monitor the fetal heart rate pattern.
D. Administer oxygen via a non-rebreather mask.
Correct Answer: C
Explanation: Early decelerations are typically caused by fetal head compression during
contractions and are considered a benign finding. They usually mirror the contraction and
do not require clinical intervention other than continued monitoring. If the decelerations
were late or variable, more aggressive interventions such as repositioning or oxygen
therapy would be warranted.
2. A client at 34 weeks gestation is receiving magnesium sulfate for preeclampsia. Which
assessment finding should the nurse report to the provider immediately?
A. Urinary output of 40 mL per hour.
B. Deep tendon reflexes of 2+.
C. Respiratory rate of 10 breaths per minute.
,D. Generalized edema in the lower extremities.
Correct Answer: C
Explanation: A respiratory rate of less than 12 breaths per minute is a primary sign of
magnesium sulfate toxicity and requires immediate cessation of the medication. The nurse
should also be prepared to administer calcium gluconate, which is the specific antagonist
for magnesium. Monitoring for decreased urinary output and loss of deep tendon reflexes
are also critical components of magnesium sulfate administration.
3. The nurse is caring for a newborn immediately following birth. Which action is the priority
to prevent heat loss through evaporation?
A. Dry the newborn thoroughly with a warm towel.
B. Place the newborn on a pre-warmed radiant warmer.
C. Keep the newborn away from air conditioning vents.
D. Place the newborn in skin-to-skin contact with the mother.
Correct Answer: A
Explanation: Heat loss through evaporation occurs when moisture on the skin is
converted into vapor, which is the most significant source of heat loss in the delivery room.
Drying the infant immediately after birth removes the moisture and prevents this rapid
cooling. Other methods like radiant warmers address radiation, while skin-to-skin contact
primarily addresses conduction.
, 4. A nurse is teaching a postpartum client about the characteristics of lochia rubra. Which of
the following information should the nurse include?
A. It is bright red in color and contains small clots.
B. It typically lasts from day 4 to day 10 postpartum.
C. It should contain large clots greater than 3 cm.
D. It consists of old blood, serum, and leukocytes.
Correct Answer: A
Explanation: Lochia rubra is the first stage of vaginal discharge after childbirth and is
characterized by a bright red color. It typically lasts for the first 1 to 3 days postpartum and
may contain small, pea-sized clots. The presence of large clots or a return to rubra after
serosa has begun should be reported to the healthcare provider.
5. A nurse is assessing a client in the transition phase of the first stage of labor. Which clinical
manifestation should the nurse expect to observe?
A. The client reports an urge to push or a feeling of rectal pressure.
B. The client is talkative and eager to follow instructions.
C. Contractions are occurring every 5 to 10 minutes.
D. The cervix is dilated to 4 centimeters.
Correct Answer: A
Nursing Q&A with Rationale | Fortis College
1. A nurse is assessing a client in the first stage of labor and notes the presence of early
decelerations on the fetal monitor. Which action should the nurse take next?
A. Prepare for an emergency cesarean section.
B. Increase the rate of the primary intravenous infusion.
C. Continue to monitor the fetal heart rate pattern.
D. Administer oxygen via a non-rebreather mask.
Correct Answer: C
Explanation: Early decelerations are typically caused by fetal head compression during
contractions and are considered a benign finding. They usually mirror the contraction and
do not require clinical intervention other than continued monitoring. If the decelerations
were late or variable, more aggressive interventions such as repositioning or oxygen
therapy would be warranted.
2. A client at 34 weeks gestation is receiving magnesium sulfate for preeclampsia. Which
assessment finding should the nurse report to the provider immediately?
A. Urinary output of 40 mL per hour.
B. Deep tendon reflexes of 2+.
C. Respiratory rate of 10 breaths per minute.
,D. Generalized edema in the lower extremities.
Correct Answer: C
Explanation: A respiratory rate of less than 12 breaths per minute is a primary sign of
magnesium sulfate toxicity and requires immediate cessation of the medication. The nurse
should also be prepared to administer calcium gluconate, which is the specific antagonist
for magnesium. Monitoring for decreased urinary output and loss of deep tendon reflexes
are also critical components of magnesium sulfate administration.
3. The nurse is caring for a newborn immediately following birth. Which action is the priority
to prevent heat loss through evaporation?
A. Dry the newborn thoroughly with a warm towel.
B. Place the newborn on a pre-warmed radiant warmer.
C. Keep the newborn away from air conditioning vents.
D. Place the newborn in skin-to-skin contact with the mother.
Correct Answer: A
Explanation: Heat loss through evaporation occurs when moisture on the skin is
converted into vapor, which is the most significant source of heat loss in the delivery room.
Drying the infant immediately after birth removes the moisture and prevents this rapid
cooling. Other methods like radiant warmers address radiation, while skin-to-skin contact
primarily addresses conduction.
, 4. A nurse is teaching a postpartum client about the characteristics of lochia rubra. Which of
the following information should the nurse include?
A. It is bright red in color and contains small clots.
B. It typically lasts from day 4 to day 10 postpartum.
C. It should contain large clots greater than 3 cm.
D. It consists of old blood, serum, and leukocytes.
Correct Answer: A
Explanation: Lochia rubra is the first stage of vaginal discharge after childbirth and is
characterized by a bright red color. It typically lasts for the first 1 to 3 days postpartum and
may contain small, pea-sized clots. The presence of large clots or a return to rubra after
serosa has begun should be reported to the healthcare provider.
5. A nurse is assessing a client in the transition phase of the first stage of labor. Which clinical
manifestation should the nurse expect to observe?
A. The client reports an urge to push or a feeling of rectal pressure.
B. The client is talkative and eager to follow instructions.
C. Contractions are occurring every 5 to 10 minutes.
D. The cervix is dilated to 4 centimeters.
Correct Answer: A
