NUR 231 MATERNAL NURSING
COMPREHENSIVE EXAM QUESTIONS
AND ANSWERS
1. A nurse is monitoring a client receiving Magnesium Sulfate for preeclampsia. Which
assessment finding is the most critical to report to the provider?
A. Respiratory rate of 14 breaths/minute
B. Urinary output of 20 mL/hour over the last 2 hours
C. Deep tendon reflexes of +2
D. Serum magnesium level of 6 mEq/L
Answer: B
Conceptual Explanation: Magnesium is excreted primarily via the kidneys. A decrease in
urinary output (less than 30 mL/hr) can lead to toxic accumulation of magnesium sulfate,
which is life-threatening.
2. Which fetal heart rate pattern should the nurse identify as indicating umbilical cord
compression during labor?
A. Variable decelerations
B. Late decelerations
,C. Early decelerations
D. Accelerations
Answer: A
Conceptual Explanation: Variable decelerations are caused by cord compression. Early
decelerations relate to head compression, while late decelerations indicate uteroplacental
insufficiency.
3. A client at 34 weeks gestation presents with painless, bright red vaginal bleeding. Which
condition should the nurse suspect?
A. Abruptio placentae
B. Placenta previa
C. Preterm labor
D. Ruptured uterus
Answer: B
Conceptual Explanation: Painless, bright red vaginal bleeding in the third trimester is the
hallmark sign of placenta previa. Abruptio placentae usually presents with painful, dark red
bleeding and a board-like abdomen.
4. A nurse is caring for a client in the fourth stage of labor. The fundus is noted to be boggy
and displaced to the right. Which action should the nurse take first?
A. Assist the client to void
, B. Administer oxytocin
C. Perform a fundal massage
D. Notify the healthcare provider
Answer: A
Conceptual Explanation: A fundus displaced to the right typically indicates a full bladder,
which prevents uterine contraction. Assisting the client to void is the priority to allow the
uterus to return to the midline and contract.
5. A newborn has a heart rate of 110, a weak cry, some flexion of extremities, a grimace when
stimulated, and a pink body with blue extremities. What is the Apgar score?
A. 6
B. 5
C. 7
D. 8
Answer: A
Conceptual Explanation: Heart rate (110) = 2; Cry (weak) = 1; Muscle tone (some flexion)
= 1; Reflex (grimace) = 1; Color (acrocyanosis) = 1. Total = 6.
6. A nurse is providing education to a pregnant client about the 1-hour oral glucose tolerance
test. Which statement indicates the client understands the procedure?
A. I need to fast for 12 hours before the test.
COMPREHENSIVE EXAM QUESTIONS
AND ANSWERS
1. A nurse is monitoring a client receiving Magnesium Sulfate for preeclampsia. Which
assessment finding is the most critical to report to the provider?
A. Respiratory rate of 14 breaths/minute
B. Urinary output of 20 mL/hour over the last 2 hours
C. Deep tendon reflexes of +2
D. Serum magnesium level of 6 mEq/L
Answer: B
Conceptual Explanation: Magnesium is excreted primarily via the kidneys. A decrease in
urinary output (less than 30 mL/hr) can lead to toxic accumulation of magnesium sulfate,
which is life-threatening.
2. Which fetal heart rate pattern should the nurse identify as indicating umbilical cord
compression during labor?
A. Variable decelerations
B. Late decelerations
,C. Early decelerations
D. Accelerations
Answer: A
Conceptual Explanation: Variable decelerations are caused by cord compression. Early
decelerations relate to head compression, while late decelerations indicate uteroplacental
insufficiency.
3. A client at 34 weeks gestation presents with painless, bright red vaginal bleeding. Which
condition should the nurse suspect?
A. Abruptio placentae
B. Placenta previa
C. Preterm labor
D. Ruptured uterus
Answer: B
Conceptual Explanation: Painless, bright red vaginal bleeding in the third trimester is the
hallmark sign of placenta previa. Abruptio placentae usually presents with painful, dark red
bleeding and a board-like abdomen.
4. A nurse is caring for a client in the fourth stage of labor. The fundus is noted to be boggy
and displaced to the right. Which action should the nurse take first?
A. Assist the client to void
, B. Administer oxytocin
C. Perform a fundal massage
D. Notify the healthcare provider
Answer: A
Conceptual Explanation: A fundus displaced to the right typically indicates a full bladder,
which prevents uterine contraction. Assisting the client to void is the priority to allow the
uterus to return to the midline and contract.
5. A newborn has a heart rate of 110, a weak cry, some flexion of extremities, a grimace when
stimulated, and a pink body with blue extremities. What is the Apgar score?
A. 6
B. 5
C. 7
D. 8
Answer: A
Conceptual Explanation: Heart rate (110) = 2; Cry (weak) = 1; Muscle tone (some flexion)
= 1; Reflex (grimace) = 1; Color (acrocyanosis) = 1. Total = 6.
6. A nurse is providing education to a pregnant client about the 1-hour oral glucose tolerance
test. Which statement indicates the client understands the procedure?
A. I need to fast for 12 hours before the test.
