NUR 202/NUR202 Exam 2 V3 | Maternal-Newborn
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a client who is at 36 weeks of gestation and has a prescription for a
nonstress test (NST). Which of the following results should the nurse identify as a reactive
NST?
A. Absence of late decelerations after spontaneous uterine contractions.
B. Presence of at least two fetal movements during the 20-minute testing window.
C. Fetal heart rate baseline of 140/min with moderate variability.
D. Fetal heart rate accelerations of 15/min for 15 seconds twice in a 20-minute period.
Correct Answer: D
Explanation: A reactive nonstress test is defined by the presence of at least two fetal heart
rate accelerations within a 20-minute window. Each acceleration must peak at least 15
beats per minute above the baseline and last for at least 15 seconds. This finding indicates
fetal well-being and a functional fetal central nervous system.
2. A nurse is monitoring a client who is in the active phase of labor and has an external fetal
monitor. The nurse notes late decelerations on the monitor strip. Which of the following
actions should the nurse take first?
A. Increase the rate of the maintenance IV fluid infusion.
B. Administer oxygen via a non-rebreather face mask at 10 L/min.
,C. Assist the client into a side-lying position.
D. Notify the primary healthcare provider.
Correct Answer: C
Explanation: Late decelerations are caused by uteroplacental insufficiency and require
immediate intervention to improve fetal oxygenation. Repositioning the client to a side-
lying position is the priority action because it relieves pressure on the vena cava and
improves placental perfusion. After repositioning, the nurse should then consider oxygen
administration and increasing IV fluids.
3. A nurse is assessing a postpartum client 4 hours after delivery. The fundus is firm, two
fingerbreadths above the umbilicus, and deviated to the right. Which of the following is the
priority nursing intervention?
A. Massage the fundus until it is firm and midline.
B. Assist the client to the bathroom to void.
C. Notify the provider of potential uterine atony.
D. Administer a dose of oxytocin as prescribed.
Correct Answer: B
Explanation: A fundus that is displaced above the umbilicus and to the right indicates a
distended bladder. A full bladder prevents the uterus from contracting effectively, which
increases the risk of postpartum hemorrhage. Assisting the client to void will allow the
uterus to return to the midline and contract properly.
,4. A nurse is providing teaching to a client who is at 30 weeks of gestation and has a new
diagnosis of gestational diabetes mellitus. Which of the following statements should the
nurse include in the teaching?
A. Your blood glucose levels will likely return to normal after delivery.
B. You should avoid all carbohydrates to maintain stable blood sugar levels.
C. You will need to take oral hypoglycemic agents until the end of your pregnancy.
D. Exercise should be limited to prevent episodes of hypoglycemia.
Correct Answer: A
Explanation: Gestational diabetes is a condition where glucose intolerance develops
during pregnancy and usually resolves after the birth of the infant. However, women who
develop gestational diabetes are at a significantly higher risk for developing Type 2
diabetes later in life. Management typically involves diet, exercise, and sometimes insulin if
blood sugars are not controlled by lifestyle changes alone.
5. A nurse is assessing a newborn 1 minute after birth and notes the following: heart rate
110/min, slow/weak cry, some flexion of the extremities, grimace when suctioned, and body
pink with blue extremities. What is the Apgar score?
A. 5
B. 8
C. 7
D. 6
, Correct Answer: D
Explanation: The Apgar score is calculated as follows: Heart rate >100 (2 points),
slow/weak cry (1 point), some flexion (1 point), grimace (1 point), and acrocyanosis (1
point). Adding these together results in a total score of 6. A score of 6 indicates that the
newborn may require some resuscitation and close monitoring.
6. A nurse is caring for a client receiving magnesium sulfate for preeclampsia. Which of the
following findings should the nurse report to the provider as a sign of toxicity?
A. Deep tendon reflexes of 2+
B. Urinary output of 40 mL/hr
C. Blood pressure of 150/95 mmHg
D. Respiratory rate of 10/min
Correct Answer: D
Explanation: Magnesium sulfate toxicity causes central nervous system depression,
leading to respiratory depression. A respiratory rate of less than 12/min is a primary
indicator of toxicity and requires immediate cessation of the infusion. Other signs of
toxicity include the loss of deep tendon reflexes and a significant drop in urinary output.
7. A nurse is assessing a client who is at 32 weeks of gestation and reports painless, bright red
vaginal bleeding. The nurse should suspect which of the following conditions?
A. Placenta previa
B. Abruptio placentae
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a client who is at 36 weeks of gestation and has a prescription for a
nonstress test (NST). Which of the following results should the nurse identify as a reactive
NST?
A. Absence of late decelerations after spontaneous uterine contractions.
B. Presence of at least two fetal movements during the 20-minute testing window.
C. Fetal heart rate baseline of 140/min with moderate variability.
D. Fetal heart rate accelerations of 15/min for 15 seconds twice in a 20-minute period.
Correct Answer: D
Explanation: A reactive nonstress test is defined by the presence of at least two fetal heart
rate accelerations within a 20-minute window. Each acceleration must peak at least 15
beats per minute above the baseline and last for at least 15 seconds. This finding indicates
fetal well-being and a functional fetal central nervous system.
2. A nurse is monitoring a client who is in the active phase of labor and has an external fetal
monitor. The nurse notes late decelerations on the monitor strip. Which of the following
actions should the nurse take first?
A. Increase the rate of the maintenance IV fluid infusion.
B. Administer oxygen via a non-rebreather face mask at 10 L/min.
,C. Assist the client into a side-lying position.
D. Notify the primary healthcare provider.
Correct Answer: C
Explanation: Late decelerations are caused by uteroplacental insufficiency and require
immediate intervention to improve fetal oxygenation. Repositioning the client to a side-
lying position is the priority action because it relieves pressure on the vena cava and
improves placental perfusion. After repositioning, the nurse should then consider oxygen
administration and increasing IV fluids.
3. A nurse is assessing a postpartum client 4 hours after delivery. The fundus is firm, two
fingerbreadths above the umbilicus, and deviated to the right. Which of the following is the
priority nursing intervention?
A. Massage the fundus until it is firm and midline.
B. Assist the client to the bathroom to void.
C. Notify the provider of potential uterine atony.
D. Administer a dose of oxytocin as prescribed.
Correct Answer: B
Explanation: A fundus that is displaced above the umbilicus and to the right indicates a
distended bladder. A full bladder prevents the uterus from contracting effectively, which
increases the risk of postpartum hemorrhage. Assisting the client to void will allow the
uterus to return to the midline and contract properly.
,4. A nurse is providing teaching to a client who is at 30 weeks of gestation and has a new
diagnosis of gestational diabetes mellitus. Which of the following statements should the
nurse include in the teaching?
A. Your blood glucose levels will likely return to normal after delivery.
B. You should avoid all carbohydrates to maintain stable blood sugar levels.
C. You will need to take oral hypoglycemic agents until the end of your pregnancy.
D. Exercise should be limited to prevent episodes of hypoglycemia.
Correct Answer: A
Explanation: Gestational diabetes is a condition where glucose intolerance develops
during pregnancy and usually resolves after the birth of the infant. However, women who
develop gestational diabetes are at a significantly higher risk for developing Type 2
diabetes later in life. Management typically involves diet, exercise, and sometimes insulin if
blood sugars are not controlled by lifestyle changes alone.
5. A nurse is assessing a newborn 1 minute after birth and notes the following: heart rate
110/min, slow/weak cry, some flexion of the extremities, grimace when suctioned, and body
pink with blue extremities. What is the Apgar score?
A. 5
B. 8
C. 7
D. 6
, Correct Answer: D
Explanation: The Apgar score is calculated as follows: Heart rate >100 (2 points),
slow/weak cry (1 point), some flexion (1 point), grimace (1 point), and acrocyanosis (1
point). Adding these together results in a total score of 6. A score of 6 indicates that the
newborn may require some resuscitation and close monitoring.
6. A nurse is caring for a client receiving magnesium sulfate for preeclampsia. Which of the
following findings should the nurse report to the provider as a sign of toxicity?
A. Deep tendon reflexes of 2+
B. Urinary output of 40 mL/hr
C. Blood pressure of 150/95 mmHg
D. Respiratory rate of 10/min
Correct Answer: D
Explanation: Magnesium sulfate toxicity causes central nervous system depression,
leading to respiratory depression. A respiratory rate of less than 12/min is a primary
indicator of toxicity and requires immediate cessation of the infusion. Other signs of
toxicity include the loss of deep tendon reflexes and a significant drop in urinary output.
7. A nurse is assessing a client who is at 32 weeks of gestation and reports painless, bright red
vaginal bleeding. The nurse should suspect which of the following conditions?
A. Placenta previa
B. Abruptio placentae
