NUR 202/NUR202 Exam 4 V2 | Maternal-Newborn
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a client who is 2 hours postpartum and exhibits a boggy uterus
displaced to the right of the midline. Which action should the nurse take first?
A. Administer oxytocin via intravenous infusion.
B. Assist the client to the bathroom to void.
C. Perform vigorous fundal massage.
D. Notify the provider of potential hemorrhage.
Correct Answer: B
Explanation: A displaced uterus to the right of the midline is a classic sign of bladder
distention, which prevents the uterus from contracting effectively. Assisting the client to
void will allow the uterus to return to the midline and contract, thereby reducing the risk of
hemorrhage. The nurse should reassess the fundus after the client voids to ensure it is firm
and midline.
2. A newborn’s APGAR score at 1 minute is 8, and at 5 minutes it is 9. The nurse notes the
infant has a heart rate of 110 bpm, a lusty cry, well-flexed extremities, and acrocyanosis.
What is the most appropriate nursing intervention?
A. Provide routine newborn care and continue to monitor.
B. Place the infant in a radiant warmer for observation.
,C. Initiate positive pressure ventilation immediately.
D. Administer a bolus of neonatal normal saline.
Correct Answer: A
Explanation: An APGAR score between 7 and 10 is considered normal and indicates the
newborn is transitioning well to extrauterine life. Acrocyanosis, or blue hands and feet, is a
common finding in the first 24 to 48 hours of life. The nurse should proceed with standard
care, including maintaining thermoregulation and skin-to-skin contact.
3. A nurse is assessing a client receiving magnesium sulfate for preeclampsia. Which 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. Client reports feeling warm and flushed.
Correct Answer: C
Explanation: A respiratory rate below 12 breaths per minute is a sign of magnesium
sulfate toxicity and requires immediate intervention, such as stopping the infusion and
administering calcium gluconate. While flushing is a common side effect, respiratory
depression and loss of deep tendon reflexes are critical warnings. Monitoring urine output
is also vital, but 40 mL/hr is above the minimum threshold of 30 mL/hr.
, 4. Which of the following findings in a newborn should the nurse identify as a manifestation
of neonatal abstinence syndrome (NAS)?
A. Excessive high-pitched crying and tremors.
B. Decreased muscle tone and lethargy.
C. Low-grade fever and bradycardia.
D. Increased appetite and slow weight gain.
Correct Answer: A
Explanation: Neonatal abstinence syndrome occurs when a newborn withdraws from
substances used by the mother during pregnancy. Characteristic signs include CNS
irritability, such as high-pitched crying, tremors, and hyperreflexia, as well as
gastrointestinal dysfunction. Nurses must use standardized scoring tools to determine the
severity of the withdrawal and the need for pharmacological intervention.
5. A nurse is teaching a postpartum client about the transition of lochia. Which statement by
the client indicates an understanding of the teaching?
A. ‘Lochia rubra will last for about 2 weeks before turning brown.’
B. ‘If I see bright red blood after 3 weeks, it is just my period returning.’
C. ‘My lochia will turn from red to pinkish-brown to creamy white.’
D. ‘I should expect the discharge to have a foul odor for the first week.’
Correct Answer: C
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a client who is 2 hours postpartum and exhibits a boggy uterus
displaced to the right of the midline. Which action should the nurse take first?
A. Administer oxytocin via intravenous infusion.
B. Assist the client to the bathroom to void.
C. Perform vigorous fundal massage.
D. Notify the provider of potential hemorrhage.
Correct Answer: B
Explanation: A displaced uterus to the right of the midline is a classic sign of bladder
distention, which prevents the uterus from contracting effectively. Assisting the client to
void will allow the uterus to return to the midline and contract, thereby reducing the risk of
hemorrhage. The nurse should reassess the fundus after the client voids to ensure it is firm
and midline.
2. A newborn’s APGAR score at 1 minute is 8, and at 5 minutes it is 9. The nurse notes the
infant has a heart rate of 110 bpm, a lusty cry, well-flexed extremities, and acrocyanosis.
What is the most appropriate nursing intervention?
A. Provide routine newborn care and continue to monitor.
B. Place the infant in a radiant warmer for observation.
,C. Initiate positive pressure ventilation immediately.
D. Administer a bolus of neonatal normal saline.
Correct Answer: A
Explanation: An APGAR score between 7 and 10 is considered normal and indicates the
newborn is transitioning well to extrauterine life. Acrocyanosis, or blue hands and feet, is a
common finding in the first 24 to 48 hours of life. The nurse should proceed with standard
care, including maintaining thermoregulation and skin-to-skin contact.
3. A nurse is assessing a client receiving magnesium sulfate for preeclampsia. Which 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. Client reports feeling warm and flushed.
Correct Answer: C
Explanation: A respiratory rate below 12 breaths per minute is a sign of magnesium
sulfate toxicity and requires immediate intervention, such as stopping the infusion and
administering calcium gluconate. While flushing is a common side effect, respiratory
depression and loss of deep tendon reflexes are critical warnings. Monitoring urine output
is also vital, but 40 mL/hr is above the minimum threshold of 30 mL/hr.
, 4. Which of the following findings in a newborn should the nurse identify as a manifestation
of neonatal abstinence syndrome (NAS)?
A. Excessive high-pitched crying and tremors.
B. Decreased muscle tone and lethargy.
C. Low-grade fever and bradycardia.
D. Increased appetite and slow weight gain.
Correct Answer: A
Explanation: Neonatal abstinence syndrome occurs when a newborn withdraws from
substances used by the mother during pregnancy. Characteristic signs include CNS
irritability, such as high-pitched crying, tremors, and hyperreflexia, as well as
gastrointestinal dysfunction. Nurses must use standardized scoring tools to determine the
severity of the withdrawal and the need for pharmacological intervention.
5. A nurse is teaching a postpartum client about the transition of lochia. Which statement by
the client indicates an understanding of the teaching?
A. ‘Lochia rubra will last for about 2 weeks before turning brown.’
B. ‘If I see bright red blood after 3 weeks, it is just my period returning.’
C. ‘My lochia will turn from red to pinkish-brown to creamy white.’
D. ‘I should expect the discharge to have a foul odor for the first week.’
Correct Answer: C
