PNR 203/PNR203 Exam 2 V3 | Maternal-Newborn
Nursing Q&A with Rationale | Fortis College
1. A nurse is assessing a client at 32 weeks gestation who has been diagnosed with severe
preeclampsia. Which of the following findings should the nurse report to the provider
immediately?
A. Urinary output of 25 mL/hr
B. Deep tendon reflexes of 2+
C. Client reports of fetal movement
D. Blood pressure of 140/90 mmHg
Correct Answer: A
Explanation: A urinary output of less than 30 mL/hr is a significant finding that indicates
potential renal failure or worsening preeclampsia. The nurse must monitor intake and
output closely to detect signs of oliguria. This finding requires immediate medical
intervention to prevent further complications like eclampsia.
2. The nurse is monitoring a client in labor and notes variable decelerations on the fetal heart
rate (FHR) monitor. What is the priority nursing action?
A. Increase the rate of the IV infusion
B. Change the client’s position to side-lying
C. Prepare for an immediate cesarean section
,D. Administer oxygen via non-rebreather mask
Correct Answer: B
Explanation: Variable decelerations are typically caused by umbilical cord compression
during contractions. Repositioning the client to a side-lying or knee-chest position can
relieve pressure on the cord and improve fetal oxygenation. This is the initial nursing
action before escalating to oxygen or more invasive procedures.
3. A client in the active phase of the first stage of labor is requesting pain medication. Which
action should the nurse take before administering an opioid analgesic?
A. Check the client’s temperature to rule out infection
B. Assess the fetal heart rate for at least one minute
C. Ask the client to sign a consent form for the medication
D. Perform a vaginal examination to determine cervical dilation
Correct Answer: D
Explanation: Opioid analgesics should not be given if the client is too close to delivery, as
they can cause respiratory depression in the newborn. Performing a vaginal exam ensures
that the client is not in the transition phase where birth is imminent. The nurse must
balance maternal comfort with neonatal safety during the labor process.
4. Which of the following findings is considered a positive sign of pregnancy?
A. Visualization of the fetus via ultrasound
, B. Amenorrhea for two consecutive cycles
C. Positive serum pregnancy test
D. Softening of the lower uterine segment
Correct Answer: A
Explanation: Positive signs of pregnancy are those that are attributed only to the presence
of a fetus. Ultrasound visualization, fetal heart tones, and fetal movement felt by the
provider are the only definitive signs. Other signs like amenorrhea or pregnancy tests are
considered presumptive or probable.
5. A nurse is caring for a client who is receiving Magnesium Sulfate for preeclampsia. Which
assessment finding indicates toxicity?
A. Respiratory rate of 10 breaths per minute
B. Deep tendon reflexes of 3+
C. Urine output of 50 mL in the last hour
D. Serum magnesium level of 6 mEq/L
Correct Answer: A
Explanation: Magnesium Sulfate is a central nervous system depressant, and a respiratory
rate below 12 per minute is a sign of toxicity. The nurse must also monitor for the loss of
deep tendon reflexes and decreased urinary output. If toxicity is suspected, the infusion
must be stopped and calcium gluconate should be administered.
Nursing Q&A with Rationale | Fortis College
1. A nurse is assessing a client at 32 weeks gestation who has been diagnosed with severe
preeclampsia. Which of the following findings should the nurse report to the provider
immediately?
A. Urinary output of 25 mL/hr
B. Deep tendon reflexes of 2+
C. Client reports of fetal movement
D. Blood pressure of 140/90 mmHg
Correct Answer: A
Explanation: A urinary output of less than 30 mL/hr is a significant finding that indicates
potential renal failure or worsening preeclampsia. The nurse must monitor intake and
output closely to detect signs of oliguria. This finding requires immediate medical
intervention to prevent further complications like eclampsia.
2. The nurse is monitoring a client in labor and notes variable decelerations on the fetal heart
rate (FHR) monitor. What is the priority nursing action?
A. Increase the rate of the IV infusion
B. Change the client’s position to side-lying
C. Prepare for an immediate cesarean section
,D. Administer oxygen via non-rebreather mask
Correct Answer: B
Explanation: Variable decelerations are typically caused by umbilical cord compression
during contractions. Repositioning the client to a side-lying or knee-chest position can
relieve pressure on the cord and improve fetal oxygenation. This is the initial nursing
action before escalating to oxygen or more invasive procedures.
3. A client in the active phase of the first stage of labor is requesting pain medication. Which
action should the nurse take before administering an opioid analgesic?
A. Check the client’s temperature to rule out infection
B. Assess the fetal heart rate for at least one minute
C. Ask the client to sign a consent form for the medication
D. Perform a vaginal examination to determine cervical dilation
Correct Answer: D
Explanation: Opioid analgesics should not be given if the client is too close to delivery, as
they can cause respiratory depression in the newborn. Performing a vaginal exam ensures
that the client is not in the transition phase where birth is imminent. The nurse must
balance maternal comfort with neonatal safety during the labor process.
4. Which of the following findings is considered a positive sign of pregnancy?
A. Visualization of the fetus via ultrasound
, B. Amenorrhea for two consecutive cycles
C. Positive serum pregnancy test
D. Softening of the lower uterine segment
Correct Answer: A
Explanation: Positive signs of pregnancy are those that are attributed only to the presence
of a fetus. Ultrasound visualization, fetal heart tones, and fetal movement felt by the
provider are the only definitive signs. Other signs like amenorrhea or pregnancy tests are
considered presumptive or probable.
5. A nurse is caring for a client who is receiving Magnesium Sulfate for preeclampsia. Which
assessment finding indicates toxicity?
A. Respiratory rate of 10 breaths per minute
B. Deep tendon reflexes of 3+
C. Urine output of 50 mL in the last hour
D. Serum magnesium level of 6 mEq/L
Correct Answer: A
Explanation: Magnesium Sulfate is a central nervous system depressant, and a respiratory
rate below 12 per minute is a sign of toxicity. The nurse must also monitor for the loss of
deep tendon reflexes and decreased urinary output. If toxicity is suspected, the infusion
must be stopped and calcium gluconate should be administered.
