BSN Maternal-Newborn and Women's Health Nursing 1 — Questions and Answers
Question 1: A nurse assesses a newborn at 1 minute of life and assigns the following: heart rate 118 bpm, weak cry, some flexion of extremities, grimace to suction, body pink with blue extremities. What is the Apgar score?
- 6 (Correct answer)
- 7
- 5
- 8
Correct answer: 6
Scoring: HR >100 (2), weak cry (1), some flexion (1), grimace (1), body pink with acrocyanosis (1) = 6 total.
Question 2: A patient at 38 weeks' gestation presents with sudden, painless, bright red vaginal bleeding. The nurse suspects which condition?
- Placenta previa (Correct answer)
- Abruptio placentae
- Premature rupture of membranes
- Bloody show of impending labor
Correct answer: Placenta previa
Placenta previa classically presents with painless bright red vaginal bleeding in the third trimester as the low-lying placenta separates.
Question 3: A laboring patient's external fetal monitor shows variable decelerations with cord compression pattern. Which nursing action is the priority?
- Change the patient's position and administer oxygen via face mask (Correct answer)
- Prepare for immediate cesarean delivery
- Increase the IV oxytocin infusion rate
- Document the finding and reassess in 15 minutes
Correct answer: Change the patient's position and administer oxygen via face mask
Position changes (e.g., lateral decubitus or knee-chest) relieve cord compression, and supplemental oxygen improves fetal oxygenation.
Question 4: A patient who is 2 hours postpartum has a boggy uterus palpated at 2 fingerbreadths above the umbilicus. The priority nursing action is:
- Massage the uterine fundus firmly until it becomes firm (Correct answer)
- Assist the patient to the bathroom to empty the bladder
- Increase the IV oxytocin infusion rate immediately
- Apply ice packs to the fundus to promote vasoconstriction
Correct answer: Massage the uterine fundus firmly until it becomes firm
Uterine massage stimulates the uterine muscles to contract and is the first-line intervention for a boggy (atonic) uterus.
Question 5: A nurse is caring for a patient with preeclampsia who is receiving IV magnesium sulfate. Which assessment finding indicates magnesium toxicity?
- Respiratory rate of 10 breaths/min and absent deep tendon reflexes (Correct answer)
- Blood pressure of 148/94 mmHg
- Urinary output of 35 mL/hr
- Mild headache and visual blurring
Correct answer: Respiratory rate of 10 breaths/min and absent deep tendon reflexes
Respiratory depression and loss of deep tendon reflexes are signs of magnesium toxicity requiring immediate discontinuation of the infusion.
Question 6: A breastfeeding mother asks why her baby's stools changed from dark green-black (meconium) to yellow and seedy. The nurse correctly explains that this change indicates:
- The newborn is receiving adequate breast milk (transitional to milk stools) (Correct answer)
- The newborn may have a milk protein allergy
- The formula should be changed to a soy-based product
- This is a sign of jaundice and requires medical evaluation
Correct answer: The newborn is receiving adequate breast milk (transitional to milk stools)
The progression from meconium to transitional stools to yellow seedy stools reflects the newborn's digestion of mature breast milk and confirms adequate intake.
BSN Maternal-Newborn and Women's Health Nursing 1
A nurse assesses a newborn at 1 minute of life and assigns the following: heart rate 118 bpm, weak cry, some flexion of extremities, grimace to suction, body pink with blue extremities.
What is the Apgar score?