PNR 203/PNR203 Exam 4 V3 | Maternal-Newborn
Nursing Q&A with Rationale | Fortis College
1. A nurse is monitoring a client receiving Magnesium Sulfate for preeclampsia. Which
assessment finding should the nurse report immediately?
A. Blood pressure of 148/92 mmHg
B. Deep tendon reflexes of 2+
C. Respiratory rate of 10 breaths per minute
D. Urine output of 40 mL per hour
Correct Answer: C
Explanation: A respiratory rate below 12 breaths per minute is a primary sign of
magnesium sulfate toxicity. The nurse must monitor respirations, deep tendon reflexes,
and urinary output closely during infusion. If toxicity is suspected, the infusion must be
stopped and calcium gluconate should be administered as an antidote.
2. When assessing a client 2 hours postpartum, the nurse finds the fundus is boggy and
displaced to the right. What is the priority nursing action?
A. Administer oxytocin as ordered
B. Massage the fundus until firm
C. Notify the healthcare provider immediately
D. Assist the client to the bathroom to void
,Correct Answer: D
Explanation: A displaced fundus to the right usually indicates a distended bladder, which
prevents the uterus from contracting effectively. Assisting the client to void will allow the
uterus to return to the midline and contract. Massaging is important, but correcting the
displacement by emptying the bladder is the specific priority for this finding.
3. A newborn has a heart rate of 110 bpm, a slow/weak cry, some flexion of extremities,
grimace when stimulated, and a pink body with blue extremities. What is the APGAR score?
A. 5
B. 6
C. 7
D. 8
Correct Answer: B
Explanation: The score is calculated as follows: Heart rate >100 (2 points), slow/weak cry
(1 point), some flexion (1 point), grimace (1 point), and acrocyanosis (1 point). This totals
6 points, indicating the newborn requires some assistance or closer observation. APGAR
scores are typically performed at 1 and 5 minutes after birth.
4. A client at 32 weeks gestation presents with painless, bright red vaginal bleeding. Which
condition should the nurse suspect?
A. Abruptio placentae
B. Placenta previa
, C. Preterm labor
D. Uterine rupture
Correct Answer: B
Explanation: Painless, bright red vaginal bleeding in the second or third trimester is a
classic sign of placenta previa. Unlike abruptio placentae, there is typically no abdominal
pain or board-like rigidity. Vaginal examinations are strictly contraindicated until the
location of the placenta is confirmed by ultrasound.
5. The nurse is preparing to administer Vitamin K (phytonadione) to a newborn. What is the
primary rationale for this medication?
A. To stimulate the production of red blood cells
B. To prevent hemorrhagic disease of the newborn
C. To prevent ophthalmia neonatorum
D. To boost the newborn’s immune system
Correct Answer: B
Explanation: Newborns are born with low levels of Vitamin K because it does not cross the
placenta easily and the sterile gut cannot yet produce it. Vitamin K is essential for the
synthesis of clotting factors in the liver. Administering this intramuscularly shortly after
birth prevents potentially fatal bleeding episodes.
Nursing Q&A with Rationale | Fortis College
1. A nurse is monitoring a client receiving Magnesium Sulfate for preeclampsia. Which
assessment finding should the nurse report immediately?
A. Blood pressure of 148/92 mmHg
B. Deep tendon reflexes of 2+
C. Respiratory rate of 10 breaths per minute
D. Urine output of 40 mL per hour
Correct Answer: C
Explanation: A respiratory rate below 12 breaths per minute is a primary sign of
magnesium sulfate toxicity. The nurse must monitor respirations, deep tendon reflexes,
and urinary output closely during infusion. If toxicity is suspected, the infusion must be
stopped and calcium gluconate should be administered as an antidote.
2. When assessing a client 2 hours postpartum, the nurse finds the fundus is boggy and
displaced to the right. What is the priority nursing action?
A. Administer oxytocin as ordered
B. Massage the fundus until firm
C. Notify the healthcare provider immediately
D. Assist the client to the bathroom to void
,Correct Answer: D
Explanation: A displaced fundus to the right usually indicates a distended bladder, which
prevents the uterus from contracting effectively. Assisting the client to void will allow the
uterus to return to the midline and contract. Massaging is important, but correcting the
displacement by emptying the bladder is the specific priority for this finding.
3. A newborn has a heart rate of 110 bpm, a slow/weak cry, some flexion of extremities,
grimace when stimulated, and a pink body with blue extremities. What is the APGAR score?
A. 5
B. 6
C. 7
D. 8
Correct Answer: B
Explanation: The score is calculated as follows: Heart rate >100 (2 points), slow/weak cry
(1 point), some flexion (1 point), grimace (1 point), and acrocyanosis (1 point). This totals
6 points, indicating the newborn requires some assistance or closer observation. APGAR
scores are typically performed at 1 and 5 minutes after birth.
4. A client at 32 weeks gestation presents with painless, bright red vaginal bleeding. Which
condition should the nurse suspect?
A. Abruptio placentae
B. Placenta previa
, C. Preterm labor
D. Uterine rupture
Correct Answer: B
Explanation: Painless, bright red vaginal bleeding in the second or third trimester is a
classic sign of placenta previa. Unlike abruptio placentae, there is typically no abdominal
pain or board-like rigidity. Vaginal examinations are strictly contraindicated until the
location of the placenta is confirmed by ultrasound.
5. The nurse is preparing to administer Vitamin K (phytonadione) to a newborn. What is the
primary rationale for this medication?
A. To stimulate the production of red blood cells
B. To prevent hemorrhagic disease of the newborn
C. To prevent ophthalmia neonatorum
D. To boost the newborn’s immune system
Correct Answer: B
Explanation: Newborns are born with low levels of Vitamin K because it does not cross the
placenta easily and the sterile gut cannot yet produce it. Vitamin K is essential for the
synthesis of clotting factors in the liver. Administering this intramuscularly shortly after
birth prevents potentially fatal bleeding episodes.
