NUR 202/NUR202 Exam 2 V2 | Maternal-Newborn
Nursing Q&A with Rationale | Fortis College
1. A nurse is monitoring a client receiving magnesium sulfate for preeclampsia. Which finding
should the nurse identify as a priority to report to the provider?
A. Urinary output of 20 mL/hr
B. Blood pressure 150/98 mmHg
C. Deep tendon reflexes of 2+
D. Respiratory rate of 14/min
Correct Answer: A
Explanation: Magnesium sulfate is excreted by the kidneys, and a urinary output of less
than 30 mL/hr indicates potential toxicity. Reduced renal clearance can lead to life-
threatening complications such as respiratory arrest or cardiac collapse. The nurse must
immediately notify the provider and monitor for other signs of magnesium toxicity such as
absent reflexes.
2. A newborn’s APGAR score is assessed at 1 minute after birth. The baby has a heart rate of
110/min, a weak cry, some flexion of the extremities, grimacing when stimulated, and a pink
body with blue extremities. What is the calculated APGAR score?
A. 5
B. 7
,C. 6
D. 8
Correct Answer: C
Explanation: The score is calculated as follows: HR > 100 (2 points), weak cry (1 point),
some flexion (1 point), grimace (1 point), and acrocyanosis (1 point), totaling 6. An APGAR
score of 6 indicates moderate distress and may require stimulation or oxygen intervention.
The assessment should be repeated at 5 minutes to determine the neonate’s adaptation to
extrauterine life.
3. A nurse is caring for a client in the active phase of the first stage of labor. The fetal heart
rate (FHR) monitor shows late decelerations. Which action should the nurse take first?
A. Increase the rate of the IV fluid infusion
B. Assist the client into a lateral position
C. Administer oxygen via a nonrebreather mask
D. Perform a sterile vaginal examination
Correct Answer: B
Explanation: Late decelerations are caused by uteroplacental insufficiency and require
immediate intervention to improve fetal oxygenation. Positioning the client on their side
relieves pressure on the inferior vena cava and improves blood flow to the placenta. After
repositioning, the nurse should then consider oxygen administration and IV boluses as per
protocol.
, 4. Which medication should the nurse anticipate administering to a client at 28 weeks of
gestation who is Rh-negative and has an unsensitized antibody screen?
A. Rho(D) Immune Globulin
B. Betamethasone
C. Terbutaline
D. Methylergonovine
Correct Answer: A
Explanation: Rho(D) Immune Globulin is administered to Rh-negative mothers at 28
weeks of gestation to prevent hemolytic disease of the newborn in future pregnancies. This
medication works by suppressing the immune response of the Rh-negative mother to Rh-
positive red blood cells. If the baby is found to be Rh-positive after birth, a second dose will
be administered within 72 hours.
5. A nurse is assessing a client who is 2 hours postpartum and notes a boggy uterus that is
displaced to the right. Which action should the nurse take first?
A. Massage the fundus until firm
B. Assist the client to the bathroom to void
C. Administer oxytocin IV
D. Check the client’s blood pressure
Correct Answer: B
Nursing Q&A with Rationale | Fortis College
1. A nurse is monitoring a client receiving magnesium sulfate for preeclampsia. Which finding
should the nurse identify as a priority to report to the provider?
A. Urinary output of 20 mL/hr
B. Blood pressure 150/98 mmHg
C. Deep tendon reflexes of 2+
D. Respiratory rate of 14/min
Correct Answer: A
Explanation: Magnesium sulfate is excreted by the kidneys, and a urinary output of less
than 30 mL/hr indicates potential toxicity. Reduced renal clearance can lead to life-
threatening complications such as respiratory arrest or cardiac collapse. The nurse must
immediately notify the provider and monitor for other signs of magnesium toxicity such as
absent reflexes.
2. A newborn’s APGAR score is assessed at 1 minute after birth. The baby has a heart rate of
110/min, a weak cry, some flexion of the extremities, grimacing when stimulated, and a pink
body with blue extremities. What is the calculated APGAR score?
A. 5
B. 7
,C. 6
D. 8
Correct Answer: C
Explanation: The score is calculated as follows: HR > 100 (2 points), weak cry (1 point),
some flexion (1 point), grimace (1 point), and acrocyanosis (1 point), totaling 6. An APGAR
score of 6 indicates moderate distress and may require stimulation or oxygen intervention.
The assessment should be repeated at 5 minutes to determine the neonate’s adaptation to
extrauterine life.
3. A nurse is caring for a client in the active phase of the first stage of labor. The fetal heart
rate (FHR) monitor shows late decelerations. Which action should the nurse take first?
A. Increase the rate of the IV fluid infusion
B. Assist the client into a lateral position
C. Administer oxygen via a nonrebreather mask
D. Perform a sterile vaginal examination
Correct Answer: B
Explanation: Late decelerations are caused by uteroplacental insufficiency and require
immediate intervention to improve fetal oxygenation. Positioning the client on their side
relieves pressure on the inferior vena cava and improves blood flow to the placenta. After
repositioning, the nurse should then consider oxygen administration and IV boluses as per
protocol.
, 4. Which medication should the nurse anticipate administering to a client at 28 weeks of
gestation who is Rh-negative and has an unsensitized antibody screen?
A. Rho(D) Immune Globulin
B. Betamethasone
C. Terbutaline
D. Methylergonovine
Correct Answer: A
Explanation: Rho(D) Immune Globulin is administered to Rh-negative mothers at 28
weeks of gestation to prevent hemolytic disease of the newborn in future pregnancies. This
medication works by suppressing the immune response of the Rh-negative mother to Rh-
positive red blood cells. If the baby is found to be Rh-positive after birth, a second dose will
be administered within 72 hours.
5. A nurse is assessing a client who is 2 hours postpartum and notes a boggy uterus that is
displaced to the right. Which action should the nurse take first?
A. Massage the fundus until firm
B. Assist the client to the bathroom to void
C. Administer oxytocin IV
D. Check the client’s blood pressure
Correct Answer: B
