NUR 230 MATERNAL NURSING
COMPREHENSIVE EXAM QUESTIONS
AND ANSWERS
1. A nurse is caring for a client at 32 weeks gestation who is receiving magnesium sulfate for
preeclampsia. Which finding should the nurse prioritize as a sign of magnesium toxicity?
A. Blood pressure of 150/96 mmHg
B. Increased respiratory rate of 22/min
C. Urinary output of 40 mL/hr
D. Absent deep tendon reflexes
Answer: D
Conceptual Explanation: Magnesium sulfate is a CNS depressant. Loss of deep tendon
reflexes (DTRs) is an early sign of toxicity that precedes respiratory depression.
2. Which of the following findings in a newborn should the nurse report to the provider
immediately?
A. Acrocyanosis in a 2-hour-old infant
B. Milia across the bridge of the nose
,C. Erythema toxicum on the trunk
D. Substernal retractions and nasal flaring
Answer: D
Conceptual Explanation: Substernal retractions and nasal flaring are clinical signs of
respiratory distress syndrome (RDS) and require immediate intervention.
3. A client is in the active phase of the first stage of labor. The fetal heart rate (FHR) shows
late decelerations. What is the priority nursing action?
A. Increase the rate of oxytocin infusion
B. Perform a vaginal exam to check for cord prolapse
C. Administer oxygen at 2 L/min via nasal cannula
D. Turn the client to a side-lying position
Answer: D
Conceptual Explanation: Late decelerations indicate uteroplacental insufficiency. The
priority is to improve blood flow by repositioning the mother to the side (usually left).
4. A nurse is reviewing the laboratory results of a client at 28 weeks gestation. Which result
requires further follow-up?
A. Hemoglobin 11.5 g/dL
B. WBC count 12,000/mm3
C. Platelet count 200,000/mm3
, D. 1-hour Glucose Tolerance Test (GTT) result of 155 mg/dL
Answer: D
Conceptual Explanation: A 1-hour GTT result above 130-140 mg/dL is abnormal and
requires a 3-hour diagnostic glucose tolerance test to rule out gestational diabetes.
5. Which medication is contraindicated for a client experiencing postpartum hemorrhage who
has a history of asthma?
A. Carboprost tromethamine (Hemabate)
B. Methylergonovine
C. Oxytocin
D. Misoprostol
Answer: A
Conceptual Explanation: Carboprost (Hemabate) causes bronchoconstriction and is
contraindicated in patients with a history of asthma.
6. During a prenatal visit, a client asks about the ‘bloody show.’ The nurse explains that this
is:
A. A sign of placental abruption
B. The expulsion of the mucus plug as the cervix ripens
C. Active bleeding from a cervical laceration
D. The rupture of the amniotic membranes
COMPREHENSIVE EXAM QUESTIONS
AND ANSWERS
1. A nurse is caring for a client at 32 weeks gestation who is receiving magnesium sulfate for
preeclampsia. Which finding should the nurse prioritize as a sign of magnesium toxicity?
A. Blood pressure of 150/96 mmHg
B. Increased respiratory rate of 22/min
C. Urinary output of 40 mL/hr
D. Absent deep tendon reflexes
Answer: D
Conceptual Explanation: Magnesium sulfate is a CNS depressant. Loss of deep tendon
reflexes (DTRs) is an early sign of toxicity that precedes respiratory depression.
2. Which of the following findings in a newborn should the nurse report to the provider
immediately?
A. Acrocyanosis in a 2-hour-old infant
B. Milia across the bridge of the nose
,C. Erythema toxicum on the trunk
D. Substernal retractions and nasal flaring
Answer: D
Conceptual Explanation: Substernal retractions and nasal flaring are clinical signs of
respiratory distress syndrome (RDS) and require immediate intervention.
3. A client is in the active phase of the first stage of labor. The fetal heart rate (FHR) shows
late decelerations. What is the priority nursing action?
A. Increase the rate of oxytocin infusion
B. Perform a vaginal exam to check for cord prolapse
C. Administer oxygen at 2 L/min via nasal cannula
D. Turn the client to a side-lying position
Answer: D
Conceptual Explanation: Late decelerations indicate uteroplacental insufficiency. The
priority is to improve blood flow by repositioning the mother to the side (usually left).
4. A nurse is reviewing the laboratory results of a client at 28 weeks gestation. Which result
requires further follow-up?
A. Hemoglobin 11.5 g/dL
B. WBC count 12,000/mm3
C. Platelet count 200,000/mm3
, D. 1-hour Glucose Tolerance Test (GTT) result of 155 mg/dL
Answer: D
Conceptual Explanation: A 1-hour GTT result above 130-140 mg/dL is abnormal and
requires a 3-hour diagnostic glucose tolerance test to rule out gestational diabetes.
5. Which medication is contraindicated for a client experiencing postpartum hemorrhage who
has a history of asthma?
A. Carboprost tromethamine (Hemabate)
B. Methylergonovine
C. Oxytocin
D. Misoprostol
Answer: A
Conceptual Explanation: Carboprost (Hemabate) causes bronchoconstriction and is
contraindicated in patients with a history of asthma.
6. During a prenatal visit, a client asks about the ‘bloody show.’ The nurse explains that this
is:
A. A sign of placental abruption
B. The expulsion of the mucus plug as the cervix ripens
C. Active bleeding from a cervical laceration
D. The rupture of the amniotic membranes
