PNR 203/PNR203 Exam 1 V2 | Maternal-Newborn
Nursing Q&A with Rationale | Fortis College
1. A nurse is calculating the estimated date of delivery (EDD) using Nagele’s rule for a client
whose last menstrual period began on September 10th. Which of the following dates should
the nurse identify as the EDD?
A. June 3rd
B. June 17th
C. May 17th
D. December 17th
Correct Answer: B
Explanation: Nagele’s rule involves subtracting three months and adding seven days to the
first day of the last menstrual period. September minus three months is June, and 10 plus
seven is 17, resulting in June 17th. This method assumes a standard 28-day cycle and is the
standard calculation tool for prenatal care.
2. A nurse is assessing a client at 12 weeks of gestation and notes a bluish-purple
discoloration of the vaginal mucosa. Which of the following terms should the nurse use to
document this finding?
A. Goodell’s sign
B. Hegar’s sign
,C. Chadwick’s sign
D. Ballottement
Correct Answer: C
Explanation: Chadwick’s sign is the bluish-purple color of the cervix and vaginal mucosa
caused by increased vascularity during pregnancy. Goodell’s sign refers to the softening of
the cervical tip, while Hegar’s sign is the softening of the lower uterine segment. These are
all considered probable signs of pregnancy observed by the examiner.
3. A nurse is caring for a client who is in the first stage of labor and notes a fetal heart rate
(FHR) pattern showing late decelerations. Which of the following actions should the nurse
take first?
A. Administer oxygen via nonrebreather mask at 8-10 L/min
B. Turn the client to a side-lying position
C. Increase the rate of the maintenance IV fluid
D. Notify the provider immediately
Correct Answer: B
Explanation: Late decelerations are caused by uteroplacental insufficiency and require
immediate intervention to improve blood flow. The first step in the protocol is to reposition
the client to a lateral position to relieve pressure on the inferior vena cava. Oxygen
administration and increasing IV fluids are subsequent steps in intrauterine resuscitation.
,4. A nurse is reviewing the laboratory results of a client who is at 28 weeks of gestation.
Which of the following findings should the nurse report to the provider?
A. Hgb 10.5 g/dL
B. WBC count 12,000/mm3
C. Hct 34%
D. Platelets 200,000/mm3
Correct Answer: A
Explanation: A hemoglobin level below 11 g/dL in the first or third trimester, or below
10.5 g/dL in the second trimester, indicates anemia. While physiologic anemia is common
due to plasma volume expansion, this level requires follow-up for iron deficiency. The
other values listed are within normal physiological ranges for a pregnant client.
5. A nurse is providing teaching to a client about a nonstress test (NST). Which of the
following statements should the nurse include?
A. The test will take about 10 minutes to complete
B. You will need to remain NPO for 4 hours before the test
C. This test measures the baby’s response to contractions
D. You will press a button when you feel the baby move
Correct Answer: D
, Explanation: During an NST, the client is asked to press a marker button whenever they
feel fetal movement to correlate movement with FHR accelerations. A reactive NST is
defined by two or more accelerations in a 20-minute period. Unlike the contraction stress
test, no contractions are required for this assessment.
6. A nurse is caring for a client who is at 34 weeks of gestation and has a prescription for
magnesium sulfate IV for preeclampsia. Which of the following findings is a priority for the
nurse to report?
A. Urinary output of 40 mL/hr
B. Respiratory rate of 10/min
C. Absent clonus
D. Generalized flushing and warmth
Correct Answer: B
Explanation: A respiratory rate of less than 12/min is a sign of magnesium toxicity and
requires immediate cessation of the infusion. Magnesium sulfate is a central nervous
system depressant used to prevent seizures in preeclamptic patients. Other signs of toxicity
include absent deep tendon reflexes and a significant drop in urinary output below 30
mL/hr.
7. A nurse is caring for a client who is in the postpartum period and has developed a boggy
uterus. Which of the following is the initial nursing action?
A. Massage the fundus until firm
Nursing Q&A with Rationale | Fortis College
1. A nurse is calculating the estimated date of delivery (EDD) using Nagele’s rule for a client
whose last menstrual period began on September 10th. Which of the following dates should
the nurse identify as the EDD?
A. June 3rd
B. June 17th
C. May 17th
D. December 17th
Correct Answer: B
Explanation: Nagele’s rule involves subtracting three months and adding seven days to the
first day of the last menstrual period. September minus three months is June, and 10 plus
seven is 17, resulting in June 17th. This method assumes a standard 28-day cycle and is the
standard calculation tool for prenatal care.
2. A nurse is assessing a client at 12 weeks of gestation and notes a bluish-purple
discoloration of the vaginal mucosa. Which of the following terms should the nurse use to
document this finding?
A. Goodell’s sign
B. Hegar’s sign
,C. Chadwick’s sign
D. Ballottement
Correct Answer: C
Explanation: Chadwick’s sign is the bluish-purple color of the cervix and vaginal mucosa
caused by increased vascularity during pregnancy. Goodell’s sign refers to the softening of
the cervical tip, while Hegar’s sign is the softening of the lower uterine segment. These are
all considered probable signs of pregnancy observed by the examiner.
3. A nurse is caring for a client who is in the first stage of labor and notes a fetal heart rate
(FHR) pattern showing late decelerations. Which of the following actions should the nurse
take first?
A. Administer oxygen via nonrebreather mask at 8-10 L/min
B. Turn the client to a side-lying position
C. Increase the rate of the maintenance IV fluid
D. Notify the provider immediately
Correct Answer: B
Explanation: Late decelerations are caused by uteroplacental insufficiency and require
immediate intervention to improve blood flow. The first step in the protocol is to reposition
the client to a lateral position to relieve pressure on the inferior vena cava. Oxygen
administration and increasing IV fluids are subsequent steps in intrauterine resuscitation.
,4. A nurse is reviewing the laboratory results of a client who is at 28 weeks of gestation.
Which of the following findings should the nurse report to the provider?
A. Hgb 10.5 g/dL
B. WBC count 12,000/mm3
C. Hct 34%
D. Platelets 200,000/mm3
Correct Answer: A
Explanation: A hemoglobin level below 11 g/dL in the first or third trimester, or below
10.5 g/dL in the second trimester, indicates anemia. While physiologic anemia is common
due to plasma volume expansion, this level requires follow-up for iron deficiency. The
other values listed are within normal physiological ranges for a pregnant client.
5. A nurse is providing teaching to a client about a nonstress test (NST). Which of the
following statements should the nurse include?
A. The test will take about 10 minutes to complete
B. You will need to remain NPO for 4 hours before the test
C. This test measures the baby’s response to contractions
D. You will press a button when you feel the baby move
Correct Answer: D
, Explanation: During an NST, the client is asked to press a marker button whenever they
feel fetal movement to correlate movement with FHR accelerations. A reactive NST is
defined by two or more accelerations in a 20-minute period. Unlike the contraction stress
test, no contractions are required for this assessment.
6. A nurse is caring for a client who is at 34 weeks of gestation and has a prescription for
magnesium sulfate IV for preeclampsia. Which of the following findings is a priority for the
nurse to report?
A. Urinary output of 40 mL/hr
B. Respiratory rate of 10/min
C. Absent clonus
D. Generalized flushing and warmth
Correct Answer: B
Explanation: A respiratory rate of less than 12/min is a sign of magnesium toxicity and
requires immediate cessation of the infusion. Magnesium sulfate is a central nervous
system depressant used to prevent seizures in preeclamptic patients. Other signs of toxicity
include absent deep tendon reflexes and a significant drop in urinary output below 30
mL/hr.
7. A nurse is caring for a client who is in the postpartum period and has developed a boggy
uterus. Which of the following is the initial nursing action?
A. Massage the fundus until firm
