PNR 203/PNR203 Final Exam V1 | Maternal-
Newborn Nursing Q&A with Rationale | Fortis
College
1. A nurse is calculating the estimated date of delivery (EDD) using Naegele’s rule for a client
whose last menstrual period (LMP) began on June 10th. Which date should the nurse identify
as the EDD?
A. March 3rd
B. March 17th
C. March 24th
D. April 17th
Correct Answer: B
Explanation: Naegele’s rule involves subtracting three months and adding seven days to
the first day of the last menstrual period. Starting from June 10th, subtracting three months
leads to March 10th. Adding seven days results in a final EDD of March 17th.
2. A nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. Which of
the following findings should the nurse report to the provider as a sign of magnesium
toxicity?
A. Blood pressure 150/96 mmHg
B. Deep tendon reflexes 2+
,C. Respiratory rate 10/min
D. Urinary output 40 mL/hr
Correct Answer: C
Explanation: A respiratory rate below 12/min is a primary sign of magnesium sulfate
toxicity and requires immediate intervention. The nurse should also monitor for the loss of
deep tendon reflexes and a significant drop in blood pressure. The antidote, calcium
gluconate, must be available at the bedside whenever magnesium sulfate is infused.
3. A nurse is assessing a client who is at 34 weeks of gestation and reports sudden, severe
abdominal pain and dark red vaginal bleeding. The nurse should suspect which of the
following complications?
A. Placenta previa
B. Abruptio placentae
C. Ectopic pregnancy
D. Spontaneous abortion
Correct Answer: B
Explanation: Abruptio placentae is characterized by painful vaginal bleeding, often dark
red, and a board-like, tender abdomen. In contrast, placenta previa typically presents as
painless, bright red bleeding. This condition is a medical emergency that can lead to fetal
distress and maternal shock.
, 4. A nurse is performing an APGAR assessment on a newborn 1 minute after birth. The
newborn has a heart rate of 110/min, a weak cry, some flexion of the extremities, grimacing
when stimulated, and a pink body with blue extremities. What APGAR score should the nurse
assign?
A. 6
B. 5
C. 7
D. 8
Correct Answer: A
Explanation: The newborn receives 2 points for heart rate (>100), 1 point for respiratory
effort (weak cry), 1 point for muscle tone (some flexion), 1 point for reflex irritability
(grimace), and 1 point for color (acrocyanosis). Adding these results in a total APGAR score
of 6. This score indicates the need for close observation and potential intervention.
5. A nurse is assessing a client who is 2 hours postpartum. The nurse notes that the fundus is
firm, 2 cm above the umbilicus, and displaced to the right. Which of the following actions
should the nurse take?
A. Massage the fundus until it is midline.
B. Assist the client to the bathroom to void.
C. Administer methylergonovine intramuscularly.
D. Notify the provider of potential internal bleeding.
Newborn Nursing Q&A with Rationale | Fortis
College
1. A nurse is calculating the estimated date of delivery (EDD) using Naegele’s rule for a client
whose last menstrual period (LMP) began on June 10th. Which date should the nurse identify
as the EDD?
A. March 3rd
B. March 17th
C. March 24th
D. April 17th
Correct Answer: B
Explanation: Naegele’s rule involves subtracting three months and adding seven days to
the first day of the last menstrual period. Starting from June 10th, subtracting three months
leads to March 10th. Adding seven days results in a final EDD of March 17th.
2. A nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. Which of
the following findings should the nurse report to the provider as a sign of magnesium
toxicity?
A. Blood pressure 150/96 mmHg
B. Deep tendon reflexes 2+
,C. Respiratory rate 10/min
D. Urinary output 40 mL/hr
Correct Answer: C
Explanation: A respiratory rate below 12/min is a primary sign of magnesium sulfate
toxicity and requires immediate intervention. The nurse should also monitor for the loss of
deep tendon reflexes and a significant drop in blood pressure. The antidote, calcium
gluconate, must be available at the bedside whenever magnesium sulfate is infused.
3. A nurse is assessing a client who is at 34 weeks of gestation and reports sudden, severe
abdominal pain and dark red vaginal bleeding. The nurse should suspect which of the
following complications?
A. Placenta previa
B. Abruptio placentae
C. Ectopic pregnancy
D. Spontaneous abortion
Correct Answer: B
Explanation: Abruptio placentae is characterized by painful vaginal bleeding, often dark
red, and a board-like, tender abdomen. In contrast, placenta previa typically presents as
painless, bright red bleeding. This condition is a medical emergency that can lead to fetal
distress and maternal shock.
, 4. A nurse is performing an APGAR assessment on a newborn 1 minute after birth. The
newborn has a heart rate of 110/min, a weak cry, some flexion of the extremities, grimacing
when stimulated, and a pink body with blue extremities. What APGAR score should the nurse
assign?
A. 6
B. 5
C. 7
D. 8
Correct Answer: A
Explanation: The newborn receives 2 points for heart rate (>100), 1 point for respiratory
effort (weak cry), 1 point for muscle tone (some flexion), 1 point for reflex irritability
(grimace), and 1 point for color (acrocyanosis). Adding these results in a total APGAR score
of 6. This score indicates the need for close observation and potential intervention.
5. A nurse is assessing a client who is 2 hours postpartum. The nurse notes that the fundus is
firm, 2 cm above the umbilicus, and displaced to the right. Which of the following actions
should the nurse take?
A. Massage the fundus until it is midline.
B. Assist the client to the bathroom to void.
C. Administer methylergonovine intramuscularly.
D. Notify the provider of potential internal bleeding.
