NR327/NR 327 Exam 2 V3 | Maternal Child
Nursing Q&A with Rationale | Chamberlain
University
1. A nurse is monitoring a client in active labor who has an external fetal monitor. The nurse
notes a fetal heart rate (FHR) pattern characterized by a gradual decrease and return to
baseline, with the nadir occurring at the peak of the contraction. Which of the following is the
appropriate nursing action?
A. Administer oxygen via non-rebreather mask at 10 L/min.
B. Reposition the client to a side-lying position.
C. Continue to monitor the client, as this is a benign finding.
D. Notify the provider and prepare for an emergency cesarean birth.
Correct Answer: C
Rationale: The description provided identifies early decelerations, which are caused by
fetal head compression during contractions. This is considered a normal and reassuring
finding that does not require medical intervention. The nurse should continue to document
the fetal heart rate and labor progress as part of standard care.
,2. A nurse is caring for a client at 32 weeks of gestation who is receiving magnesium sulfate
for preeclampsia. Which of the following assessment findings is the most critical for the nurse
to report to the provider?
A. Blood pressure of 150/94 mmHg.
B. Feeling of warmth and flushing.
C. Presence of 2+ deep tendon reflexes.
D. Urinary output of 20 mL per hour.
Correct Answer: D
Rationale: Magnesium sulfate is excreted by the kidneys, and a urinary output of less than
30 mL per hour can lead to magnesium toxicity. The nurse must monitor intake and output
closely to ensure the client is adequately clearing the medication. Other signs of toxicity
include absent reflexes and respiratory depression, which require immediate cessation of
the infusion.
3. A client at 38 weeks of gestation presents with painless, bright red vaginal bleeding. Which
of the following diagnostic procedures should the nurse expect the provider to order first?
A. Sterile vaginal examination.
B. Transabdominal ultrasound.
C. Contraction stress test (CST).
D. Internal fetal scalp electrode placement.
,Correct Answer: B
Rationale: Painless, bright red bleeding is a classic sign of placenta previa, and a sterile
vaginal exam must be avoided until the placental location is confirmed. An ultrasound is
the definitive diagnostic tool to visualize the placenta relative to the internal cervical os.
Performing a digital exam on a previa could cause catastrophic hemorrhage for both the
mother and fetus.
4. A nurse is reviewing the lab results for a client at 28 weeks of gestation who just completed
a 1-hour glucose tolerance test (GTT). Which of the following results indicates a need for a
follow-up 3-hour GTT?
A. 110 mg/dL
B. 125 mg/dL
C. 90 mg/dL
D. 145 mg/dL
Correct Answer: D
Rationale: A blood glucose level of 130 to 140 mg/dL or higher after a 1-hour 50g glucose
load is considered positive for gestational diabetes screening. Since 145 mg/dL exceeds
this threshold, the client requires a diagnostic 3-hour oral glucose tolerance test. The 3-
hour test will provide a definitive diagnosis based on fasting and hourly intervals.
, 5. A client in the second stage of labor is experiencing shoulder dystocia. Which of the
following nursing interventions is appropriate?
A. Apply fundal pressure during contractions.
B. Administer terbutaline subcutaneously.
C. Perform the McRoberts maneuver.
D. Place the client in a high-Fowler’s position.
Correct Answer: C
Rationale: The McRoberts maneuver involves hyperflexing the mother’s legs to the
abdomen to widen the pelvic outlet and facilitate delivery. Fundal pressure is strictly
contraindicated as it may further impact the shoulder behind the symphysis pubis. The
nurse should also assist with suprapubic pressure as directed by the provider.
6. A nurse is assessing a postpartum client who is 4 hours after a vaginal delivery. The nurse
notes the fundus is boggy and displaced to the right of the midline. What is the priority
nursing action?
A. Perform fundal massage until firm.
B. Notify the provider of a possible hemorrhage.
C. Assist the client to empty her bladder.
D. Administer 0.2 mg of methylergonovine IM.
Correct Answer: C
Nursing Q&A with Rationale | Chamberlain
University
1. A nurse is monitoring a client in active labor who has an external fetal monitor. The nurse
notes a fetal heart rate (FHR) pattern characterized by a gradual decrease and return to
baseline, with the nadir occurring at the peak of the contraction. Which of the following is the
appropriate nursing action?
A. Administer oxygen via non-rebreather mask at 10 L/min.
B. Reposition the client to a side-lying position.
C. Continue to monitor the client, as this is a benign finding.
D. Notify the provider and prepare for an emergency cesarean birth.
Correct Answer: C
Rationale: The description provided identifies early decelerations, which are caused by
fetal head compression during contractions. This is considered a normal and reassuring
finding that does not require medical intervention. The nurse should continue to document
the fetal heart rate and labor progress as part of standard care.
,2. A nurse is caring for a client at 32 weeks of gestation who is receiving magnesium sulfate
for preeclampsia. Which of the following assessment findings is the most critical for the nurse
to report to the provider?
A. Blood pressure of 150/94 mmHg.
B. Feeling of warmth and flushing.
C. Presence of 2+ deep tendon reflexes.
D. Urinary output of 20 mL per hour.
Correct Answer: D
Rationale: Magnesium sulfate is excreted by the kidneys, and a urinary output of less than
30 mL per hour can lead to magnesium toxicity. The nurse must monitor intake and output
closely to ensure the client is adequately clearing the medication. Other signs of toxicity
include absent reflexes and respiratory depression, which require immediate cessation of
the infusion.
3. A client at 38 weeks of gestation presents with painless, bright red vaginal bleeding. Which
of the following diagnostic procedures should the nurse expect the provider to order first?
A. Sterile vaginal examination.
B. Transabdominal ultrasound.
C. Contraction stress test (CST).
D. Internal fetal scalp electrode placement.
,Correct Answer: B
Rationale: Painless, bright red bleeding is a classic sign of placenta previa, and a sterile
vaginal exam must be avoided until the placental location is confirmed. An ultrasound is
the definitive diagnostic tool to visualize the placenta relative to the internal cervical os.
Performing a digital exam on a previa could cause catastrophic hemorrhage for both the
mother and fetus.
4. A nurse is reviewing the lab results for a client at 28 weeks of gestation who just completed
a 1-hour glucose tolerance test (GTT). Which of the following results indicates a need for a
follow-up 3-hour GTT?
A. 110 mg/dL
B. 125 mg/dL
C. 90 mg/dL
D. 145 mg/dL
Correct Answer: D
Rationale: A blood glucose level of 130 to 140 mg/dL or higher after a 1-hour 50g glucose
load is considered positive for gestational diabetes screening. Since 145 mg/dL exceeds
this threshold, the client requires a diagnostic 3-hour oral glucose tolerance test. The 3-
hour test will provide a definitive diagnosis based on fasting and hourly intervals.
, 5. A client in the second stage of labor is experiencing shoulder dystocia. Which of the
following nursing interventions is appropriate?
A. Apply fundal pressure during contractions.
B. Administer terbutaline subcutaneously.
C. Perform the McRoberts maneuver.
D. Place the client in a high-Fowler’s position.
Correct Answer: C
Rationale: The McRoberts maneuver involves hyperflexing the mother’s legs to the
abdomen to widen the pelvic outlet and facilitate delivery. Fundal pressure is strictly
contraindicated as it may further impact the shoulder behind the symphysis pubis. The
nurse should also assist with suprapubic pressure as directed by the provider.
6. A nurse is assessing a postpartum client who is 4 hours after a vaginal delivery. The nurse
notes the fundus is boggy and displaced to the right of the midline. What is the priority
nursing action?
A. Perform fundal massage until firm.
B. Notify the provider of a possible hemorrhage.
C. Assist the client to empty her bladder.
D. Administer 0.2 mg of methylergonovine IM.
Correct Answer: C
