PNR 203/PNR203 Exam 2 V1 | Maternal-Newborn
Nursing Q&A with Rationale | Fortis College
1. A nurse is monitoring a patient receiving magnesium sulfate for preeclampsia. Which
assessment finding should the nurse report to the provider immediately?
A. Respiratory rate of 10/min
B. Deep tendon reflexes of 2+
C. Urine output of 40 mL/hr
D. Fetal heart rate of 140/min
Correct Answer: A
Explanation: Magnesium sulfate is a central nervous system depressant used to prevent
seizures in preeclampsia. A respiratory rate below 12/min is a sign of magnesium toxicity
and requires immediate intervention. The nurse should also monitor for loss of deep
tendon reflexes and decreased urinary output below 30 mL/hr.
2. A nurse is caring for a client in labor and observes late decelerations on the electronic fetal
monitor. Which action should the nurse take first?
A. Administer oxygen via nonrebreather mask
B. Increase the IV fluid infusion rate
C. Reposition the client to the lateral position
D. Notify the healthcare provider
,Correct Answer: C
Explanation: Late decelerations are indicative of uteroplacental insufficiency and fetal
distress. The first priority is to improve blood flow to the placenta by repositioning the
mother to her side to relieve pressure on the vena cava. After repositioning, the nurse
should provide oxygen, increase fluids, and then notify the provider.
3. Which of the following findings is considered a positive sign of pregnancy?
A. Positive pregnancy test
B. Fetal heart tones heard on Doppler
C. Amenorrhea
D. Quickening
Correct Answer: B
Explanation: Positive signs of pregnancy are those that can be attributed only to the
presence of a fetus, such as hearing fetal heart tones or visualization by ultrasound.
Amenorrhea and quickening are presumptive signs, which are subjective. A positive
pregnancy test is a probable sign because it measures hCG levels, which can be elevated by
other conditions.
4. A postpartum nurse is assessing a client 2 hours after delivery. The fundus is boggy and
displaced to the right of the midline. What is the priority nursing action?
A. Assist the client to the bathroom to void
B. Administer oxytocin as ordered
, C. Massage the fundus until firm
D. Document the findings as normal
Correct Answer: A
Explanation: A displaced fundus to the right or left 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, reducing the risk of hemorrhage. If
the fundus remains boggy after voiding, then fundal massage would be the next step.
5. What is the primary purpose of administering Vitamin K (Phytonadione) to a newborn
within 1 hour of birth?
A. To prevent hemorrhagic disease of the newborn
B. To stimulate the production of red blood cells
C. To prevent ophthalmia neonatorum
D. To enhance the immune system
Correct Answer: A
Explanation: Newborns are born with a sterile gut and lack the bacteria necessary to
synthesize Vitamin K, which is essential for blood clotting. Administering Vitamin K
prevents potentially fatal bleeding episodes in the first few days of life. This injection is a
standard of care in the immediate neonatal period.
Nursing Q&A with Rationale | Fortis College
1. A nurse is monitoring a patient receiving magnesium sulfate for preeclampsia. Which
assessment finding should the nurse report to the provider immediately?
A. Respiratory rate of 10/min
B. Deep tendon reflexes of 2+
C. Urine output of 40 mL/hr
D. Fetal heart rate of 140/min
Correct Answer: A
Explanation: Magnesium sulfate is a central nervous system depressant used to prevent
seizures in preeclampsia. A respiratory rate below 12/min is a sign of magnesium toxicity
and requires immediate intervention. The nurse should also monitor for loss of deep
tendon reflexes and decreased urinary output below 30 mL/hr.
2. A nurse is caring for a client in labor and observes late decelerations on the electronic fetal
monitor. Which action should the nurse take first?
A. Administer oxygen via nonrebreather mask
B. Increase the IV fluid infusion rate
C. Reposition the client to the lateral position
D. Notify the healthcare provider
,Correct Answer: C
Explanation: Late decelerations are indicative of uteroplacental insufficiency and fetal
distress. The first priority is to improve blood flow to the placenta by repositioning the
mother to her side to relieve pressure on the vena cava. After repositioning, the nurse
should provide oxygen, increase fluids, and then notify the provider.
3. Which of the following findings is considered a positive sign of pregnancy?
A. Positive pregnancy test
B. Fetal heart tones heard on Doppler
C. Amenorrhea
D. Quickening
Correct Answer: B
Explanation: Positive signs of pregnancy are those that can be attributed only to the
presence of a fetus, such as hearing fetal heart tones or visualization by ultrasound.
Amenorrhea and quickening are presumptive signs, which are subjective. A positive
pregnancy test is a probable sign because it measures hCG levels, which can be elevated by
other conditions.
4. A postpartum nurse is assessing a client 2 hours after delivery. The fundus is boggy and
displaced to the right of the midline. What is the priority nursing action?
A. Assist the client to the bathroom to void
B. Administer oxytocin as ordered
, C. Massage the fundus until firm
D. Document the findings as normal
Correct Answer: A
Explanation: A displaced fundus to the right or left 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, reducing the risk of hemorrhage. If
the fundus remains boggy after voiding, then fundal massage would be the next step.
5. What is the primary purpose of administering Vitamin K (Phytonadione) to a newborn
within 1 hour of birth?
A. To prevent hemorrhagic disease of the newborn
B. To stimulate the production of red blood cells
C. To prevent ophthalmia neonatorum
D. To enhance the immune system
Correct Answer: A
Explanation: Newborns are born with a sterile gut and lack the bacteria necessary to
synthesize Vitamin K, which is essential for blood clotting. Administering Vitamin K
prevents potentially fatal bleeding episodes in the first few days of life. This injection is a
standard of care in the immediate neonatal period.
