PNR 203/PNR203 Final Exam V3 | Maternal-
Newborn Nursing Q&A with Rationale | Fortis
College
1. A nurse is assessing a client who is at 30 weeks of gestation. The nurse notes a blood
pressure of 152/96 mmHg and 2+ protein in the urine. Which of the following conditions
should the nurse suspect?
A. Preeclampsia
B. Eclampsia
C. Gestational hypertension
D. Chronic hypertension
Correct Answer: A
Explanation: Preeclampsia is characterized by hypertension and proteinuria occurring
after 20 weeks of gestation. This condition requires careful monitoring because it can
progress to eclampsia or HELLP syndrome. The clinical presentation of 152/96 mmHg and
2+ proteinuria fits the diagnostic criteria for preeclampsia without severe features.
2. A client in the active phase of labor has fetal heart rate decelerations that begin after the
peak of the contraction and return to baseline only after the contraction ends. Which action
is the priority?
A. Increase the IV fluid rate
B. Administer oxygen via nasal cannula at 2L/min
,C. Prepare for an immediate forceps delivery
D. Change the client’s position to lateral
Correct Answer: D
Explanation: Late decelerations are indicative of uteroplacental insufficiency and require
immediate nursing intervention to improve oxygenation. The first step is to reposition the
mother to a side-lying position to remove pressure from the inferior vena cava and
improve blood flow. Other interventions include increasing IV fluids and administering
oxygen via a non-rebreather mask, not a nasal cannula.
3. Which of the following findings in a newborn within the first hour of birth should the nurse
report to the provider immediately?
A. Nasal flaring and grunting
B. Molding of the head
C. Acrocyanosis
D. Vernix caseosa in the skin folds
Correct Answer: A
Explanation: Nasal flaring and grunting are signs of respiratory distress in a newborn and
require immediate intervention. Acrocyanosis is a normal finding in the first 24-48 hours
as the peripheral circulation stabilizes. Molding and vernix caseosa are expected findings
that do not require emergency reporting.
, 4. A nurse is teaching a postpartum client about breastfeeding. Which statement by the client
indicates an understanding of the teaching?
A. “I should wash my nipples with soap before each feeding.”
B. “I will know my baby is getting enough milk if there are 6 to 8 wet diapers a day.”
C. “I will use a clock to time feedings to exactly 10 minutes per side.”
D. “I should supplement with formula if my baby seems hungry after 5 minutes.”
Correct Answer: B
Explanation: Adequate hydration and intake in a breastfed newborn are typically assessed
by the number of wet diapers, with 6 to 8 being the standard for a well-hydrated infant.
Soap should be avoided on nipples as it can cause drying and cracking. Feeding should be
baby-led rather than strictly timed to ensure the infant receives both foremilk and
hindmilk.
5. A nurse is caring for a client receiving Magnesium Sulfate for preeclampsia. The nurse
notes the client has absent deep tendon reflexes and a respiratory rate of 10/min. Which
medication should be readily available?
A. Naloxone
B. Hydralazine
C. Terbutaline
D. Calcium gluconate
Newborn Nursing Q&A with Rationale | Fortis
College
1. A nurse is assessing a client who is at 30 weeks of gestation. The nurse notes a blood
pressure of 152/96 mmHg and 2+ protein in the urine. Which of the following conditions
should the nurse suspect?
A. Preeclampsia
B. Eclampsia
C. Gestational hypertension
D. Chronic hypertension
Correct Answer: A
Explanation: Preeclampsia is characterized by hypertension and proteinuria occurring
after 20 weeks of gestation. This condition requires careful monitoring because it can
progress to eclampsia or HELLP syndrome. The clinical presentation of 152/96 mmHg and
2+ proteinuria fits the diagnostic criteria for preeclampsia without severe features.
2. A client in the active phase of labor has fetal heart rate decelerations that begin after the
peak of the contraction and return to baseline only after the contraction ends. Which action
is the priority?
A. Increase the IV fluid rate
B. Administer oxygen via nasal cannula at 2L/min
,C. Prepare for an immediate forceps delivery
D. Change the client’s position to lateral
Correct Answer: D
Explanation: Late decelerations are indicative of uteroplacental insufficiency and require
immediate nursing intervention to improve oxygenation. The first step is to reposition the
mother to a side-lying position to remove pressure from the inferior vena cava and
improve blood flow. Other interventions include increasing IV fluids and administering
oxygen via a non-rebreather mask, not a nasal cannula.
3. Which of the following findings in a newborn within the first hour of birth should the nurse
report to the provider immediately?
A. Nasal flaring and grunting
B. Molding of the head
C. Acrocyanosis
D. Vernix caseosa in the skin folds
Correct Answer: A
Explanation: Nasal flaring and grunting are signs of respiratory distress in a newborn and
require immediate intervention. Acrocyanosis is a normal finding in the first 24-48 hours
as the peripheral circulation stabilizes. Molding and vernix caseosa are expected findings
that do not require emergency reporting.
, 4. A nurse is teaching a postpartum client about breastfeeding. Which statement by the client
indicates an understanding of the teaching?
A. “I should wash my nipples with soap before each feeding.”
B. “I will know my baby is getting enough milk if there are 6 to 8 wet diapers a day.”
C. “I will use a clock to time feedings to exactly 10 minutes per side.”
D. “I should supplement with formula if my baby seems hungry after 5 minutes.”
Correct Answer: B
Explanation: Adequate hydration and intake in a breastfed newborn are typically assessed
by the number of wet diapers, with 6 to 8 being the standard for a well-hydrated infant.
Soap should be avoided on nipples as it can cause drying and cracking. Feeding should be
baby-led rather than strictly timed to ensure the infant receives both foremilk and
hindmilk.
5. A nurse is caring for a client receiving Magnesium Sulfate for preeclampsia. The nurse
notes the client has absent deep tendon reflexes and a respiratory rate of 10/min. Which
medication should be readily available?
A. Naloxone
B. Hydralazine
C. Terbutaline
D. Calcium gluconate
