NUR 231 MATERNAL NURSING
COMPREHENSIVE EXAM QUESTIONS
AND ANSWERS
1. A nurse is caring for a client at 34 weeks gestation who presents with sudden, dark red
vaginal bleeding and a board-like, tender abdomen. What is the nurse’s priority action?
A. Perform a sterile vaginal exam to assess dilation
B. Prepare the client for a scheduled induction of labor
C. Monitor fetal heart rate for at least 30 minutes
D. Administer oxygen via non-rebreather mask and start a large-bore IV
Answer: D
Conceptual Explanation: The symptoms suggest Abruptio Placentae, a medical
emergency. Oxygenation and fluid resuscitation are priorities to manage potential
hemorrhage and fetal distress. Vaginal exams are contraindicated until placenta previa is
ruled out.
2. A patient receiving Magnesium Sulfate for preeclampsia shows a respiratory rate of 10
breaths/min and absent patellar reflexes. Which medication should the nurse have available?
A. Calcium Gluconate
,B. Terbutaline
C. Naloxone
D. Oxytocin
Answer: A
Conceptual Explanation: Calcium Gluconate is the specific antidote for Magnesium Sulfate
toxicity, which is indicated here by respiratory depression and loss of deep tendon reflexes.
3. Using Naegele’s rule, calculate the Estimated Date of Delivery (EDD) for a client whose last
menstrual period began on March 10th.
A. December 3rd
B. December 17th
C. January 17th
D. November 10th
Answer: B
Conceptual Explanation: Naegele’s Rule: Subtract 3 months from the first day of the LMP
and add 7 days (March 10 - 3 months = December 10 + 7 days = December 17).
4. A nurse observes late decelerations on the fetal monitor strip. Which is the physiological
cause of this pattern?
A. Uteroplacental insufficiency
B. Fetal head compression
, C. Umbilical cord compression
D. Fetal CNS maturation
Answer: A
Conceptual Explanation: Late decelerations are caused by uteroplacental insufficiency,
meaning the fetus is not getting enough oxygen during contractions.
5. Which finding is a definitive sign of the transition phase (8-10 cm) of the first stage of
labor?
A. The client is talkative and excited
B. The client experiences an urge to push and becomes irritable
C. Contractions are every 5 to 10 minutes and mild
D. Rupture of membranes with clear fluid
Answer: B
Conceptual Explanation: During transition, the client often feels a loss of control,
irritability, and a strong urge to push (rectal pressure) as the fetus descends.
6. An infant’s APGAR score at 1 minute is: Heart rate 110, slow/irregular respiratory effort,
some flexion of extremities, grimace when stimulated, and body pink with blue extremities.
What is the score?
A. 5
B. 8
COMPREHENSIVE EXAM QUESTIONS
AND ANSWERS
1. A nurse is caring for a client at 34 weeks gestation who presents with sudden, dark red
vaginal bleeding and a board-like, tender abdomen. What is the nurse’s priority action?
A. Perform a sterile vaginal exam to assess dilation
B. Prepare the client for a scheduled induction of labor
C. Monitor fetal heart rate for at least 30 minutes
D. Administer oxygen via non-rebreather mask and start a large-bore IV
Answer: D
Conceptual Explanation: The symptoms suggest Abruptio Placentae, a medical
emergency. Oxygenation and fluid resuscitation are priorities to manage potential
hemorrhage and fetal distress. Vaginal exams are contraindicated until placenta previa is
ruled out.
2. A patient receiving Magnesium Sulfate for preeclampsia shows a respiratory rate of 10
breaths/min and absent patellar reflexes. Which medication should the nurse have available?
A. Calcium Gluconate
,B. Terbutaline
C. Naloxone
D. Oxytocin
Answer: A
Conceptual Explanation: Calcium Gluconate is the specific antidote for Magnesium Sulfate
toxicity, which is indicated here by respiratory depression and loss of deep tendon reflexes.
3. Using Naegele’s rule, calculate the Estimated Date of Delivery (EDD) for a client whose last
menstrual period began on March 10th.
A. December 3rd
B. December 17th
C. January 17th
D. November 10th
Answer: B
Conceptual Explanation: Naegele’s Rule: Subtract 3 months from the first day of the LMP
and add 7 days (March 10 - 3 months = December 10 + 7 days = December 17).
4. A nurse observes late decelerations on the fetal monitor strip. Which is the physiological
cause of this pattern?
A. Uteroplacental insufficiency
B. Fetal head compression
, C. Umbilical cord compression
D. Fetal CNS maturation
Answer: A
Conceptual Explanation: Late decelerations are caused by uteroplacental insufficiency,
meaning the fetus is not getting enough oxygen during contractions.
5. Which finding is a definitive sign of the transition phase (8-10 cm) of the first stage of
labor?
A. The client is talkative and excited
B. The client experiences an urge to push and becomes irritable
C. Contractions are every 5 to 10 minutes and mild
D. Rupture of membranes with clear fluid
Answer: B
Conceptual Explanation: During transition, the client often feels a loss of control,
irritability, and a strong urge to push (rectal pressure) as the fetus descends.
6. An infant’s APGAR score at 1 minute is: Heart rate 110, slow/irregular respiratory effort,
some flexion of extremities, grimace when stimulated, and body pink with blue extremities.
What is the score?
A. 5
B. 8
