NR327/NR 327 Exam 2 V3 | Maternal Child Nursing
Q&A with Rationale | Chamberlain University
1. A nurse is assessing a client who is at 37 weeks of gestation and has severe preeclampsia.
Which of the following findings should the nurse expect?
A. Polyuria
B. Hyporeflexia
C. Blurred vision
D. Hypotension
Correct Answer: C
Explanation: Severe preeclampsia is characterized by central nervous system irritability
due to cerebral edema. Blurred vision or visual disturbances occur as a result of retinal
arteriolar spasms. This condition requires immediate monitoring to prevent progression to
eclampsia or seizures.
2. A client in active labor has a fetal heart rate (FHR) tracing showing late decelerations.
Which of the following is the priority nursing action?
A. Perform a vaginal examination
B. Turn the client to a side-lying position
C. Increase the oxytocin infusion rate
D. Administer pain medication
,Correct Answer: B
Explanation: Late decelerations indicate uteroplacental insufficiency, which is a non-
reassuring fetal status. Positioning the client on her side increases placental perfusion by
relieving pressure on the inferior vena cava. The nurse must also discontinue oxytocin and
provide supplemental oxygen to improve fetal oxygenation.
3. A nurse is caring for a client who is receiving magnesium sulfate for the treatment of
preeclampsia. Which of the following medications should the nurse have available as an
antidote?
A. Calcium gluconate
B. Naloxone
C. Terbutaline
D. Hydralazine
Correct Answer: A
Explanation: Calcium gluconate is the specific antidote for magnesium sulfate toxicity. It
works by antagonizing the effects of magnesium at the neuromuscular junction. The nurse
should keep this medication at the bedside to treat respiratory depression or cardiac arrest
resulting from high magnesium levels.
4. Which of the following assessments is the most critical for a nurse to perform 2 hours after
a client has given birth?
A. Temperature
, B. Bowel sounds
C. Fundal consistency
D. Breast tenderness
Correct Answer: C
Explanation: Postpartum hemorrhage is a major cause of maternal mortality, often
occurring shortly after delivery. Assessing the fundal consistency ensures the uterus is firm
and contracting to minimize bleeding from the placental site. A boggy uterus requires
immediate massage to prevent excessive blood loss.
5. A nurse is assessing a newborn 1 minute after birth and finds: heart rate 110/min,
slow/irregular respiratory effort, some flexion of extremities, grimace in response to
suctioning, and a pink body with blue extremities. What is the Apgar score?
A. 5
B. 7
C. 6
D. 8
Correct Answer: C
Explanation: The Apgar score is calculated as follows: HR > 100 (2 points), slow/irregular
respirations (1 point), some flexion (1 point), grimace (1 point), and acrocyanosis (1 point).
Q&A with Rationale | Chamberlain University
1. A nurse is assessing a client who is at 37 weeks of gestation and has severe preeclampsia.
Which of the following findings should the nurse expect?
A. Polyuria
B. Hyporeflexia
C. Blurred vision
D. Hypotension
Correct Answer: C
Explanation: Severe preeclampsia is characterized by central nervous system irritability
due to cerebral edema. Blurred vision or visual disturbances occur as a result of retinal
arteriolar spasms. This condition requires immediate monitoring to prevent progression to
eclampsia or seizures.
2. A client in active labor has a fetal heart rate (FHR) tracing showing late decelerations.
Which of the following is the priority nursing action?
A. Perform a vaginal examination
B. Turn the client to a side-lying position
C. Increase the oxytocin infusion rate
D. Administer pain medication
,Correct Answer: B
Explanation: Late decelerations indicate uteroplacental insufficiency, which is a non-
reassuring fetal status. Positioning the client on her side increases placental perfusion by
relieving pressure on the inferior vena cava. The nurse must also discontinue oxytocin and
provide supplemental oxygen to improve fetal oxygenation.
3. A nurse is caring for a client who is receiving magnesium sulfate for the treatment of
preeclampsia. Which of the following medications should the nurse have available as an
antidote?
A. Calcium gluconate
B. Naloxone
C. Terbutaline
D. Hydralazine
Correct Answer: A
Explanation: Calcium gluconate is the specific antidote for magnesium sulfate toxicity. It
works by antagonizing the effects of magnesium at the neuromuscular junction. The nurse
should keep this medication at the bedside to treat respiratory depression or cardiac arrest
resulting from high magnesium levels.
4. Which of the following assessments is the most critical for a nurse to perform 2 hours after
a client has given birth?
A. Temperature
, B. Bowel sounds
C. Fundal consistency
D. Breast tenderness
Correct Answer: C
Explanation: Postpartum hemorrhage is a major cause of maternal mortality, often
occurring shortly after delivery. Assessing the fundal consistency ensures the uterus is firm
and contracting to minimize bleeding from the placental site. A boggy uterus requires
immediate massage to prevent excessive blood loss.
5. A nurse is assessing a newborn 1 minute after birth and finds: heart rate 110/min,
slow/irregular respiratory effort, some flexion of extremities, grimace in response to
suctioning, and a pink body with blue extremities. What is the Apgar score?
A. 5
B. 7
C. 6
D. 8
Correct Answer: C
Explanation: The Apgar score is calculated as follows: HR > 100 (2 points), slow/irregular
respirations (1 point), some flexion (1 point), grimace (1 point), and acrocyanosis (1 point).
