NUR 212 MATERNAL-NEWBORN NURSING GUIDE WITH
QUESTIONS AND CORRECT ANSWERS 2026
1.A pregnant client at 32 weeks gestation presents with sudden onset of
bright red vaginal bleeding without pain. The fetal heart rate is 140 bpm
with normal variability. Which condition should the nurse suspect?
A. Placenta previa
B. Placental abruption
C. Uterine rupture
D. Vasa previa
Correct Answer: A
Explanation: Painless bright red vaginal bleeding in the third trimester is
classic for placenta previa. Placental abruption typically presents with
painful bleeding and a tender, rigid uterus. Uterine rupture presents
with severe pain and fetal distress. Vasa previa also presents with
painless bleeding but is rare and typically associated with fetal heart
rate abnormalities due to fetal blood loss.
2. During labor, the fetal monitor shows late decelerations with
minimal variability. The client is receiving oxytocin at 8 mU/min.
What is the nurse's FIRST intervention?
A. Administer oxygen at 8-10 L/min via face mask
B. Discontinue the oxytocin infusion
C. Reposition the client to left lateral position
D. Increase IV fluid rate
Correct Answer: B
Explanation: Late decelerations indicate uteroplacental
, insufficiency. The first action is to stop the oxytocin to reduce
uterine contractions and improve placental perfusion. Oxygen,
repositioning, and IV fluids are important secondary interventions
but stopping the oxytocin is priority.
3. A client at 39 weeks gestation presents with ruptured membranes.
The amniotic fluid is meconium-stained (Grade III). The fetal heart
rate is 110 bpm with moderate variability. What is the most
appropriate nursing action?
A. Prepare for immediate cesarean section
B. Continue routine monitoring and prepare for delivery
C. Perform amnioinfusion immediately
D. Administer antibiotics prophylactically
Correct Answer: B
Explanation: With meconium-stained fluid but reassuring fetal
heart rate (moderate variability), routine monitoring and
preparation for delivery is appropriate. Immediate cesarean is not
indicated without fetal distress. Amnioinfusion may be considered
but isn't the first action. Antibiotics are not indicated for
meconium alone.
4. A postpartum client at 2 hours after vaginal delivery has a boggy
uterus displaced to the right. What is the most likely cause?
A. Uterine atony
B. Full bladder
C. Uterine inversion
D. Retained placental fragments
, Correct Answer: B
Explanation: A boggy uterus displaced to the right is classic for a
full bladder pushing the uterus. Uterine atony causes a boggy
midline uterus. Uterine inversion presents with severe hemorrhage
and a mass in the vagina. Retained fragments cause prolonged
bleeding but not uterine displacement.
5. A newborn at 1 minute of life has a heart rate of 90 bpm, weak
cry, some flexion of extremities, grimace with stimulation, and
blue extremities with pink trunk. What is the Apgar score?
A. 5
B. 6
C. 7
D. 4
Correct Answer: B
Explanation: Heart rate 90 = 1 point, weak cry = 1 point, some
flexion = 1 point, grimace = 1 point, blue extremities/pink trunk = 1
point. Total = 6 points. A score of 6 indicates the infant needs some
assistance.
6. A client with preeclampsia is receiving magnesium sulfate. Which
assessment finding indicates magnesium toxicity?
A. Blood pressure 150/95 mmHg
B. Urine output 30 mL/hr
C. Deep tendon reflexes 1+
D. Respiratory rate 12 breaths/min
Correct Answer: D
, Explanation: Respiratory depression (RR < 12) is a sign of
magnesium toxicity. Loss of DTRs (0-1+) is also concerning but
respiratory depression is more dangerous. BP 150/95 is still
elevated but not toxic. Urine output of 30 mL/hr is adequate
(minimum 25-30 mL/hr).
7. A pregnant client at 28 weeks presents with constant, severe
abdominal pain and vaginal bleeding. The uterus is tender and
board-like. Fetal heart rate is 90 bpm. What is the priority nursing
action?
A. Administer terbutaline 0.25 mg subcutaneously
B. Prepare for immediate cesarean delivery
C. Apply oxygen at 2 L/min via nasal cannula
D. Start a magnesium sulfate infusion
Correct Answer: B
Explanation: The presentation is classic for placental abruption
with fetal distress (FHR 90). Immediate delivery via cesarean is the
priority to save both mother and fetus. Terbutaline would decrease
contractions but doesn't address the emergency. Oxygen is
important but not the priority. Magnesium is for seizure
prophylaxis, not abruption.
8. Which finding in a newborn requires immediate intervention?
A. Acrocyanosis at 2 hours of life
B. Respiratory rate of 68 breaths/min at rest
C. Positive Moro reflex
D. Yellowish discoloration of sclera at 24 hours
QUESTIONS AND CORRECT ANSWERS 2026
1.A pregnant client at 32 weeks gestation presents with sudden onset of
bright red vaginal bleeding without pain. The fetal heart rate is 140 bpm
with normal variability. Which condition should the nurse suspect?
A. Placenta previa
B. Placental abruption
C. Uterine rupture
D. Vasa previa
Correct Answer: A
Explanation: Painless bright red vaginal bleeding in the third trimester is
classic for placenta previa. Placental abruption typically presents with
painful bleeding and a tender, rigid uterus. Uterine rupture presents
with severe pain and fetal distress. Vasa previa also presents with
painless bleeding but is rare and typically associated with fetal heart
rate abnormalities due to fetal blood loss.
2. During labor, the fetal monitor shows late decelerations with
minimal variability. The client is receiving oxytocin at 8 mU/min.
What is the nurse's FIRST intervention?
A. Administer oxygen at 8-10 L/min via face mask
B. Discontinue the oxytocin infusion
C. Reposition the client to left lateral position
D. Increase IV fluid rate
Correct Answer: B
Explanation: Late decelerations indicate uteroplacental
, insufficiency. The first action is to stop the oxytocin to reduce
uterine contractions and improve placental perfusion. Oxygen,
repositioning, and IV fluids are important secondary interventions
but stopping the oxytocin is priority.
3. A client at 39 weeks gestation presents with ruptured membranes.
The amniotic fluid is meconium-stained (Grade III). The fetal heart
rate is 110 bpm with moderate variability. What is the most
appropriate nursing action?
A. Prepare for immediate cesarean section
B. Continue routine monitoring and prepare for delivery
C. Perform amnioinfusion immediately
D. Administer antibiotics prophylactically
Correct Answer: B
Explanation: With meconium-stained fluid but reassuring fetal
heart rate (moderate variability), routine monitoring and
preparation for delivery is appropriate. Immediate cesarean is not
indicated without fetal distress. Amnioinfusion may be considered
but isn't the first action. Antibiotics are not indicated for
meconium alone.
4. A postpartum client at 2 hours after vaginal delivery has a boggy
uterus displaced to the right. What is the most likely cause?
A. Uterine atony
B. Full bladder
C. Uterine inversion
D. Retained placental fragments
, Correct Answer: B
Explanation: A boggy uterus displaced to the right is classic for a
full bladder pushing the uterus. Uterine atony causes a boggy
midline uterus. Uterine inversion presents with severe hemorrhage
and a mass in the vagina. Retained fragments cause prolonged
bleeding but not uterine displacement.
5. A newborn at 1 minute of life has a heart rate of 90 bpm, weak
cry, some flexion of extremities, grimace with stimulation, and
blue extremities with pink trunk. What is the Apgar score?
A. 5
B. 6
C. 7
D. 4
Correct Answer: B
Explanation: Heart rate 90 = 1 point, weak cry = 1 point, some
flexion = 1 point, grimace = 1 point, blue extremities/pink trunk = 1
point. Total = 6 points. A score of 6 indicates the infant needs some
assistance.
6. A client with preeclampsia is receiving magnesium sulfate. Which
assessment finding indicates magnesium toxicity?
A. Blood pressure 150/95 mmHg
B. Urine output 30 mL/hr
C. Deep tendon reflexes 1+
D. Respiratory rate 12 breaths/min
Correct Answer: D
, Explanation: Respiratory depression (RR < 12) is a sign of
magnesium toxicity. Loss of DTRs (0-1+) is also concerning but
respiratory depression is more dangerous. BP 150/95 is still
elevated but not toxic. Urine output of 30 mL/hr is adequate
(minimum 25-30 mL/hr).
7. A pregnant client at 28 weeks presents with constant, severe
abdominal pain and vaginal bleeding. The uterus is tender and
board-like. Fetal heart rate is 90 bpm. What is the priority nursing
action?
A. Administer terbutaline 0.25 mg subcutaneously
B. Prepare for immediate cesarean delivery
C. Apply oxygen at 2 L/min via nasal cannula
D. Start a magnesium sulfate infusion
Correct Answer: B
Explanation: The presentation is classic for placental abruption
with fetal distress (FHR 90). Immediate delivery via cesarean is the
priority to save both mother and fetus. Terbutaline would decrease
contractions but doesn't address the emergency. Oxygen is
important but not the priority. Magnesium is for seizure
prophylaxis, not abruption.
8. Which finding in a newborn requires immediate intervention?
A. Acrocyanosis at 2 hours of life
B. Respiratory rate of 68 breaths/min at rest
C. Positive Moro reflex
D. Yellowish discoloration of sclera at 24 hours
