NSG 432 Final Exam V3 | NSG 432
Maternal-Newborn Nursing / OB/GYN |
Actual Q&A with Rationale (NSG432 Final
Exam) | Grand Canyon University
1. A nurse is assessing a client at 34 weeks gestation who was admitted with a diagnosis of
severe preeclampsia. Which of the following findings should the nurse anticipate? (Select All
That Apply)
A. Blood pressure of 168/112 mmHg
B. 3+ protein in the urine
C. Continuous frontal headache
D. Increased urine output
E. Epigastric pain
F. Blurred vision
Correct Answer: A, B, C, E, F
Severe preeclampsia is marked by a blood pressure of 160/110 mmHg or higher and
significant proteinuria. The presence of epigastric pain indicates hepatic involvement and
the stretching of the liver capsule, which is a precursor to HELLP syndrome. Neurological
symptoms like blurred vision and persistent headaches are caused by cerebral edema and
vasospasm, requiring immediate monitoring to prevent eclampsia.
,2. A nurse is monitoring a fetal heart rate (FHR) tracing and observes a pattern of late
decelerations. Which of the following actions should the nurse take first?
A. Assist the client into a side-lying position.
B. Place the client in a supine position.
C. Increase the IV oxytocin infusion rate.
D. Administer 2 liters of oxygen via nasal cannula.
Correct Answer: A
Late decelerations are indicative of uteroplacental insufficiency, which can lead to fetal
hypoxia. The priority action is to improve placental perfusion by moving the mother to a
side-lying position to relieve pressure on the vena cava. If oxytocin is running, it should be
discontinued immediately to reduce uterine activity and allow for better oxygenation
between contractions.
3. Which of the following interventions is most effective in preventing heat loss by
evaporation in a newborn immediately after birth?
A. Placing the infant under a radiant warmer.
B. Drying the infant with warm blankets.
C. Placing the infant on a warm scale.
D. Keeping the infant away from air vents.
Correct Answer: B
, Evaporative heat loss occurs when moisture on the skin is converted to vapor. Drying the
infant immediately after birth removes the amniotic fluid and prevents this specific
mechanism of heat loss. Other methods like radiant warmers address radiation, while
avoiding drafts addresses convection.
4. A nurse is caring for a client who is in the first stage of labor. The nurse notes that the fetal
heart rate is 140/min with moderate variability and no decelerations. How should the nurse
interpret these findings?
A. A Category III fetal heart rate pattern.
B. A Category II fetal heart rate pattern.
C. An abnormal pattern requiring immediate delivery.
D. A Category I fetal heart rate pattern.
Correct Answer: D
A Category I fetal heart rate pattern is considered normal and reassuring. It includes a
baseline between 110-160/min, moderate variability, and the absence of late or variable
decelerations. This finding indicates that the fetus is currently well-oxygenated and
tolerating the stress of labor.
5. A client at 30 weeks gestation is receiving magnesium sulfate for preterm labor. Which of
the following assessments is the priority for the nurse to perform?
A. Assessment of fetal position.
B. Monitoring for vaginal bleeding.
Maternal-Newborn Nursing / OB/GYN |
Actual Q&A with Rationale (NSG432 Final
Exam) | Grand Canyon University
1. A nurse is assessing a client at 34 weeks gestation who was admitted with a diagnosis of
severe preeclampsia. Which of the following findings should the nurse anticipate? (Select All
That Apply)
A. Blood pressure of 168/112 mmHg
B. 3+ protein in the urine
C. Continuous frontal headache
D. Increased urine output
E. Epigastric pain
F. Blurred vision
Correct Answer: A, B, C, E, F
Severe preeclampsia is marked by a blood pressure of 160/110 mmHg or higher and
significant proteinuria. The presence of epigastric pain indicates hepatic involvement and
the stretching of the liver capsule, which is a precursor to HELLP syndrome. Neurological
symptoms like blurred vision and persistent headaches are caused by cerebral edema and
vasospasm, requiring immediate monitoring to prevent eclampsia.
,2. A nurse is monitoring a fetal heart rate (FHR) tracing and observes a pattern of late
decelerations. Which of the following actions should the nurse take first?
A. Assist the client into a side-lying position.
B. Place the client in a supine position.
C. Increase the IV oxytocin infusion rate.
D. Administer 2 liters of oxygen via nasal cannula.
Correct Answer: A
Late decelerations are indicative of uteroplacental insufficiency, which can lead to fetal
hypoxia. The priority action is to improve placental perfusion by moving the mother to a
side-lying position to relieve pressure on the vena cava. If oxytocin is running, it should be
discontinued immediately to reduce uterine activity and allow for better oxygenation
between contractions.
3. Which of the following interventions is most effective in preventing heat loss by
evaporation in a newborn immediately after birth?
A. Placing the infant under a radiant warmer.
B. Drying the infant with warm blankets.
C. Placing the infant on a warm scale.
D. Keeping the infant away from air vents.
Correct Answer: B
, Evaporative heat loss occurs when moisture on the skin is converted to vapor. Drying the
infant immediately after birth removes the amniotic fluid and prevents this specific
mechanism of heat loss. Other methods like radiant warmers address radiation, while
avoiding drafts addresses convection.
4. A nurse is caring for a client who is in the first stage of labor. The nurse notes that the fetal
heart rate is 140/min with moderate variability and no decelerations. How should the nurse
interpret these findings?
A. A Category III fetal heart rate pattern.
B. A Category II fetal heart rate pattern.
C. An abnormal pattern requiring immediate delivery.
D. A Category I fetal heart rate pattern.
Correct Answer: D
A Category I fetal heart rate pattern is considered normal and reassuring. It includes a
baseline between 110-160/min, moderate variability, and the absence of late or variable
decelerations. This finding indicates that the fetus is currently well-oxygenated and
tolerating the stress of labor.
5. A client at 30 weeks gestation is receiving magnesium sulfate for preterm labor. Which of
the following assessments is the priority for the nurse to perform?
A. Assessment of fetal position.
B. Monitoring for vaginal bleeding.
