UR 202/ NUR202 Exam 1 –
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Maternal-Newborn Nursing Guide|
Fortis ACTUAL EXAM 2026/2027 |
Maternal-Newborn Nursing |
Verified Q&A | Pass Guaranteed -
A+ Graded
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PART A – MULTIPLE CHOICE (Q1‑60)
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Q1 (Perioperative – NPO Guidelines): A 58-year-old male is scheduled for elective laparoscopic
cholecystectomy under general anesthesia at 0800. According to the 2026 ASA fasting
guidelines, which instruction is most appropriate for the nurse to provide?
A. "You may have a light breakfast of toast and juice up to 2 hours before surgery."
B. "No solid food after midnight, but you may drink clear liquids up to 2 hours before arrival."
C. "You may have a small amount of milk with your medications 4 hours before surgery."
D. "No food or drink of any kind after 2000 the evening before surgery."
[CORRECT] B
Rationale: The 2026 ASA fasting guidelines state clear liquids are safe up to 2 hours before
surgery, while solids require a minimum 6-hour fast. Option A violates the 6-hour solid food rule.
Option C is incorrect because milk is not a clear liquid and requires a 6-hour fast. Option D is
overly restrictive and not evidence-based; clear liquids actually improve patient comfort and
reduce aspiration risk by maintaining gastric emptying.
Q2 (Perioperative – Informed Consent): The nurse is preparing a patient for an emergency
appendectomy. The surgeon has explained the procedure, but the patient appears confused
and asks the nurse to explain it again. Which action by the nurse is most appropriate?
A. Explain the procedure in detail and have the patient sign the consent form.
B. Notify the surgeon that the patient requires further explanation before signing consent.
C. Have the patient's spouse sign the consent form as a substitute.
D. Proceed with preoperative preparation while the patient decides.
[CORRECT] B
, ationale: Informed consent is a legal and ethical requirement that must be obtained by the
R
provider performing the procedure; the nurse's role is to witness signature and ensure the
patient understands. Option A violates scope of practice as nurses cannot obtain informed
consent for surgery. Option C is incorrect unless the patient is incompetent and has a healthcare
proxy. Option D delays the ethical and legal process of ensuring truly informed consent.
Q3 (Perioperative – Malignant Hyperthermia): During surgery, the anesthesia provider notes the
patient's temperature has risen from 37.0°C to 39.8°C in 20 minutes, with muscle rigidity and
tachycardia. Which medication should the nurse prepare immediately?
A. Propofol
B. Dantrolene sodium
C. Succinylcholine
D. Atropine
[CORRECT] B
Rationale: Dantrolene sodium is the antidote for malignant hyperthermia (MH), a hypermetabolic
crisis triggered by volatile anesthetics or succinylcholine. Option A (propofol) is not indicated for
MH. Option C (succinylcholine) is actually a trigger for MH and would worsen the condition.
Option D (atropine) would further increase the already elevated heart rate and is
contraindicated.
Q4 (Perioperative – Postoperative Atelectasis): On postoperative day 1, a 67-year-old patient
after abdominal surgery has diminished breath sounds in the right lower lobe, temperature
38.2°C (100.8°F), and SpO₂ 92% on room air. Which nursing intervention is the priority?
A. Administer antipyretics and encourage oral fluids
B. Encourage deep breathing and use of incentive spirometry every hour while awake
C. Place the patient in high-Fowler's position and administer oxygen at 4 L/min
D. Contact the provider for a chest x-ray and possible antibiotic therapy
[CORRECT] B
Rationale: Atelectasis is the most common postoperative complication caused by shallow
breathing and immobility; the priority intervention is lung expansion through deep breathing and
incentive spirometry (IS). Option A treats symptoms but not the cause. Option C is supportive
but does not address the underlying alveolar collapse. Option D is premature; antibiotics are not
indicated for uncomplicated atelectasis without evidence of pneumonia.
Q5 (Perioperative – DVT Prevention): A postoperative patient is at high risk for deep vein
thrombosis (DVT). Which intervention should the nurse include in the plan of care?
A. Apply thigh-high sequential compression devices (SCDs) and encourage early ambulation
B. Maintain bed rest for 48 hours to prevent dislodgement of clots
C. Massage the patient's calves every 4 hours to promote circulation
D. Apply warm compresses to the lower extremities to dilate vessels
[CORRECT] A
Rationale: SCDs promote venous return and early ambulation activates the calf muscle pump,
both evidence-based DVT prevention strategies per AHA guidelines. Option B increases DVT
risk by promoting venous stasis. Option C is dangerous because massage could dislodge an
existing thrombus, causing a pulmonary embolism. Option D has no proven benefit for DVT
prevention and could mask symptoms of DVT.
, 6 (Perioperative – Wound Dehiscence/Evisceration): A patient on postoperative day 5 after
Q
colon resection calls out that something "gave way" in the abdominal incision. The nurse
observes loops of intestine protruding through the wound. What is the nurse's first action?
A. Push the intestines back into the abdominal cavity and cover with a sterile dressing
B. Apply a sterile saline-soaked dressing over the wound and call for immediate help
C. Place the patient in Trendelenburg position to reduce pressure on the wound
D. Remove the sutures to relieve tension on the wound edges
[CORRECT] B
Rationale: Evisceration requires immediate intervention to prevent peritonitis and hypovolemic
shock; a sterile saline-soaked dressing prevents tissue desiccation and contamination while
maintaining moisture. Option A is contraindicated because pushing organs back introduces
infection and may cause further damage. Option C (Trendelenburg) increases intra-abdominal
pressure. Option D worsens the evisceration by removing the only barrier holding tissues in
place.
Q7 (Perioperative – Ileus): On postoperative day 3, a patient who had abdominal surgery
reports nausea and has not passed flatus. Bowel sounds are absent in all four quadrants. The
abdomen is distended and tympanic. Which intervention is most appropriate?
A. Advance the diet to clear liquids and encourage ambulation
B. Maintain NPO status, insert an NG tube to low intermittent suction, and monitor I&O
C. Administer a stimulant laxative to promote bowel motility
D. Perform a digital rectal exam to assess for fecal impaction
[CORRECT] B
Rationale: Postoperative ileus is characterized by absent bowel sounds, distension, and no
flatus; management includes NPO status, NG decompression, and fluid/electrolyte monitoring.
Option A is dangerous because oral intake worsens distension and vomiting risk. Option C is
contraindicated in paralytic ileus where peristalsis is absent, not obstructed. Option D is
inappropriate and could perforate a distended bowel.
Q8 (Perioperative – Urinary Retention): A postoperative patient has not voided 8 hours after
catheter removal. The bladder scan shows 550 mL of urine. Which action should the nurse take
first?
A. Encourage the patient to void using running water and perineal stimulation
B. Insert a straight catheter to drain the bladder immediately
C. Administer bethanechol (Urecholine) to stimulate bladder contraction
D. Apply a warm compress to the suprapubic area and reassess in 2 hours
[CORRECT] A
Rationale: Non-invasive measures (running water, privacy, positioning) are the first-line
intervention for postoperative urinary retention per ERAS protocols. Option B is indicated only if
non-invasive measures fail or if the patient is uncomfortable with >500 mL. Option C requires a
provider order and is not first-line. Option D delays intervention when the patient already has
significant retention volume.
Q9 (Fluid & Electrolytes – Isotonic Fluids): A patient is admitted with hypovolemia secondary to
vomiting. The provider orders 1,000 mL of 0.9% sodium chloride (normal saline) over 8 hours.
The nurse understands that normal saline is classified as isotonic because:
A. It has the same osmolarity as plasma and expands intravascular volume
N
Maternal-Newborn Nursing Guide|
Fortis ACTUAL EXAM 2026/2027 |
Maternal-Newborn Nursing |
Verified Q&A | Pass Guaranteed -
A+ Graded
=======================================================================
=
========
PART A – MULTIPLE CHOICE (Q1‑60)
========================================================================
========
Q1 (Perioperative – NPO Guidelines): A 58-year-old male is scheduled for elective laparoscopic
cholecystectomy under general anesthesia at 0800. According to the 2026 ASA fasting
guidelines, which instruction is most appropriate for the nurse to provide?
A. "You may have a light breakfast of toast and juice up to 2 hours before surgery."
B. "No solid food after midnight, but you may drink clear liquids up to 2 hours before arrival."
C. "You may have a small amount of milk with your medications 4 hours before surgery."
D. "No food or drink of any kind after 2000 the evening before surgery."
[CORRECT] B
Rationale: The 2026 ASA fasting guidelines state clear liquids are safe up to 2 hours before
surgery, while solids require a minimum 6-hour fast. Option A violates the 6-hour solid food rule.
Option C is incorrect because milk is not a clear liquid and requires a 6-hour fast. Option D is
overly restrictive and not evidence-based; clear liquids actually improve patient comfort and
reduce aspiration risk by maintaining gastric emptying.
Q2 (Perioperative – Informed Consent): The nurse is preparing a patient for an emergency
appendectomy. The surgeon has explained the procedure, but the patient appears confused
and asks the nurse to explain it again. Which action by the nurse is most appropriate?
A. Explain the procedure in detail and have the patient sign the consent form.
B. Notify the surgeon that the patient requires further explanation before signing consent.
C. Have the patient's spouse sign the consent form as a substitute.
D. Proceed with preoperative preparation while the patient decides.
[CORRECT] B
, ationale: Informed consent is a legal and ethical requirement that must be obtained by the
R
provider performing the procedure; the nurse's role is to witness signature and ensure the
patient understands. Option A violates scope of practice as nurses cannot obtain informed
consent for surgery. Option C is incorrect unless the patient is incompetent and has a healthcare
proxy. Option D delays the ethical and legal process of ensuring truly informed consent.
Q3 (Perioperative – Malignant Hyperthermia): During surgery, the anesthesia provider notes the
patient's temperature has risen from 37.0°C to 39.8°C in 20 minutes, with muscle rigidity and
tachycardia. Which medication should the nurse prepare immediately?
A. Propofol
B. Dantrolene sodium
C. Succinylcholine
D. Atropine
[CORRECT] B
Rationale: Dantrolene sodium is the antidote for malignant hyperthermia (MH), a hypermetabolic
crisis triggered by volatile anesthetics or succinylcholine. Option A (propofol) is not indicated for
MH. Option C (succinylcholine) is actually a trigger for MH and would worsen the condition.
Option D (atropine) would further increase the already elevated heart rate and is
contraindicated.
Q4 (Perioperative – Postoperative Atelectasis): On postoperative day 1, a 67-year-old patient
after abdominal surgery has diminished breath sounds in the right lower lobe, temperature
38.2°C (100.8°F), and SpO₂ 92% on room air. Which nursing intervention is the priority?
A. Administer antipyretics and encourage oral fluids
B. Encourage deep breathing and use of incentive spirometry every hour while awake
C. Place the patient in high-Fowler's position and administer oxygen at 4 L/min
D. Contact the provider for a chest x-ray and possible antibiotic therapy
[CORRECT] B
Rationale: Atelectasis is the most common postoperative complication caused by shallow
breathing and immobility; the priority intervention is lung expansion through deep breathing and
incentive spirometry (IS). Option A treats symptoms but not the cause. Option C is supportive
but does not address the underlying alveolar collapse. Option D is premature; antibiotics are not
indicated for uncomplicated atelectasis without evidence of pneumonia.
Q5 (Perioperative – DVT Prevention): A postoperative patient is at high risk for deep vein
thrombosis (DVT). Which intervention should the nurse include in the plan of care?
A. Apply thigh-high sequential compression devices (SCDs) and encourage early ambulation
B. Maintain bed rest for 48 hours to prevent dislodgement of clots
C. Massage the patient's calves every 4 hours to promote circulation
D. Apply warm compresses to the lower extremities to dilate vessels
[CORRECT] A
Rationale: SCDs promote venous return and early ambulation activates the calf muscle pump,
both evidence-based DVT prevention strategies per AHA guidelines. Option B increases DVT
risk by promoting venous stasis. Option C is dangerous because massage could dislodge an
existing thrombus, causing a pulmonary embolism. Option D has no proven benefit for DVT
prevention and could mask symptoms of DVT.
, 6 (Perioperative – Wound Dehiscence/Evisceration): A patient on postoperative day 5 after
Q
colon resection calls out that something "gave way" in the abdominal incision. The nurse
observes loops of intestine protruding through the wound. What is the nurse's first action?
A. Push the intestines back into the abdominal cavity and cover with a sterile dressing
B. Apply a sterile saline-soaked dressing over the wound and call for immediate help
C. Place the patient in Trendelenburg position to reduce pressure on the wound
D. Remove the sutures to relieve tension on the wound edges
[CORRECT] B
Rationale: Evisceration requires immediate intervention to prevent peritonitis and hypovolemic
shock; a sterile saline-soaked dressing prevents tissue desiccation and contamination while
maintaining moisture. Option A is contraindicated because pushing organs back introduces
infection and may cause further damage. Option C (Trendelenburg) increases intra-abdominal
pressure. Option D worsens the evisceration by removing the only barrier holding tissues in
place.
Q7 (Perioperative – Ileus): On postoperative day 3, a patient who had abdominal surgery
reports nausea and has not passed flatus. Bowel sounds are absent in all four quadrants. The
abdomen is distended and tympanic. Which intervention is most appropriate?
A. Advance the diet to clear liquids and encourage ambulation
B. Maintain NPO status, insert an NG tube to low intermittent suction, and monitor I&O
C. Administer a stimulant laxative to promote bowel motility
D. Perform a digital rectal exam to assess for fecal impaction
[CORRECT] B
Rationale: Postoperative ileus is characterized by absent bowel sounds, distension, and no
flatus; management includes NPO status, NG decompression, and fluid/electrolyte monitoring.
Option A is dangerous because oral intake worsens distension and vomiting risk. Option C is
contraindicated in paralytic ileus where peristalsis is absent, not obstructed. Option D is
inappropriate and could perforate a distended bowel.
Q8 (Perioperative – Urinary Retention): A postoperative patient has not voided 8 hours after
catheter removal. The bladder scan shows 550 mL of urine. Which action should the nurse take
first?
A. Encourage the patient to void using running water and perineal stimulation
B. Insert a straight catheter to drain the bladder immediately
C. Administer bethanechol (Urecholine) to stimulate bladder contraction
D. Apply a warm compress to the suprapubic area and reassess in 2 hours
[CORRECT] A
Rationale: Non-invasive measures (running water, privacy, positioning) are the first-line
intervention for postoperative urinary retention per ERAS protocols. Option B is indicated only if
non-invasive measures fail or if the patient is uncomfortable with >500 mL. Option C requires a
provider order and is not first-line. Option D delays intervention when the patient already has
significant retention volume.
Q9 (Fluid & Electrolytes – Isotonic Fluids): A patient is admitted with hypovolemia secondary to
vomiting. The provider orders 1,000 mL of 0.9% sodium chloride (normal saline) over 8 hours.
The nurse understands that normal saline is classified as isotonic because:
A. It has the same osmolarity as plasma and expands intravascular volume
