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NUR 231 Exam 1 – Maternal Nursing | Galen
College (2026) | Advanced/Hard Difficulty |
Professional Level | 100% Pass Guaranteed |
Graded A+
1. A 32-year-old primigravida at 38 weeks gestation is admitted to the labor and delivery unit
with regular contractions. Which assessment finding should the nurse prioritize as an
indication of adequate maternal-fetal oxygenation during labor?
A. Maternal respiratory rate of 22 breaths per minute
B. Fetal heart rate baseline of 140 bpm with moderate variability
C. Maternal blood pressure of 148/92 mmHg
D. Fetal heart rate decelerations following each contraction
Correct Answer: B
Explanation: A fetal heart rate baseline of 140 bpm with moderate variability is the most
direct indicator of adequate fetal oxygenation and central nervous system function. Moderate
variability (6-25 bpm) suggests a well-oxygenated fetus. Maternal tachypnea is a sign of
distress, hypertension is a concern, and late decelerations indicate uteroplacental insufficiency.
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2. A 28-year-old primigravida at 39 weeks gestation is 4 cm dilated, 90% effaced, and at -1
station. Her contractions are 3-4 minutes apart, lasting 60 seconds, and moderate intensity.
Which phase of labor is this patient in?
A. Latent phase of the first stage
B. Active phase of the first stage
C. Transition phase of the first stage
D. Second stage of labor
Correct Answer: B
Explanation: The patient is in the active phase of the first stage of labor, characterized by
cervical dilation from 4-7 cm, effacement of 80-100%, and contractions occurring every 2-5
minutes, lasting 45-60 seconds, with moderate to strong intensity. The latent phase is 0-3 cm,
transition is 8-10 cm, and the second stage begins at full dilation.
3. A 25-year-old G1P0 at 40 weeks gestation is in active labor. Her cervix is 6 cm dilated, 100%
effaced, and the presenting part is at 0 station. The fetal heart rate tracing shows a baseline
of 130 bpm, moderate variability, and early decelerations with each contraction. What is the
most appropriate nursing action?
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A. Prepare for immediate cesarean delivery
B. Administer oxygen at 10 L/min via non-rebreather mask
C. Continue to monitor and document the fetal heart rate pattern
D. Notify the provider of non-reassuring fetal status
Correct Answer: C
Explanation: Early decelerations are a benign, reassuring fetal heart rate pattern caused by
head compression during contractions. They mirror the contraction and indicate a well-
oxygenated fetus. No intervention is needed; the nurse should continue to monitor and
document the pattern. Options A, B, and D are appropriate for non-reassuring patterns such as
late or variable decelerations.
4. A 30-year-old G2P1 at 36 weeks gestation presents with a blood pressure of 158/96 mmHg,
2+ proteinuria, and complaints of a headache and blurred vision. Which of the following
medications should the nurse anticipate administering first?
A. Labetalol 20 mg IV push
B. Magnesium sulfate 4 g IV bolus
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C. Nifedipine 10 mg orally
D. Hydralazine 5 mg IV push
Correct Answer: B
Explanation: The patient is exhibiting signs of severe preeclampsia with headache and
blurred vision, indicating central nervous system involvement. Magnesium sulfate is the first-line
medication to prevent seizures (eclampsia) in patients with severe preeclampsia.
Antihypertensives such as labetalol, nifedipine, or hydralazine are used for blood pressure
control but are secondary to seizure prophylaxis in this scenario.
5. A 22-year-old primigravida at 41 weeks gestation is receiving an oxytocin infusion for
induction of labor. The nurse notes that the patient is having contractions every 1.5 minutes,
lasting 90 seconds, and the fetal heart rate shows late decelerations. What is the priority
nursing action?
A. Decrease the oxytocin infusion rate
B. Increase the oxytocin infusion rate
C. Position the patient on her left side
D. Administer terbutaline 0.25 mg subcutaneously
NUR 231 Exam 1 – Maternal Nursing | Galen
College (2026) | Advanced/Hard Difficulty |
Professional Level | 100% Pass Guaranteed |
Graded A+
1. A 32-year-old primigravida at 38 weeks gestation is admitted to the labor and delivery unit
with regular contractions. Which assessment finding should the nurse prioritize as an
indication of adequate maternal-fetal oxygenation during labor?
A. Maternal respiratory rate of 22 breaths per minute
B. Fetal heart rate baseline of 140 bpm with moderate variability
C. Maternal blood pressure of 148/92 mmHg
D. Fetal heart rate decelerations following each contraction
Correct Answer: B
Explanation: A fetal heart rate baseline of 140 bpm with moderate variability is the most
direct indicator of adequate fetal oxygenation and central nervous system function. Moderate
variability (6-25 bpm) suggests a well-oxygenated fetus. Maternal tachypnea is a sign of
distress, hypertension is a concern, and late decelerations indicate uteroplacental insufficiency.
,2
2. A 28-year-old primigravida at 39 weeks gestation is 4 cm dilated, 90% effaced, and at -1
station. Her contractions are 3-4 minutes apart, lasting 60 seconds, and moderate intensity.
Which phase of labor is this patient in?
A. Latent phase of the first stage
B. Active phase of the first stage
C. Transition phase of the first stage
D. Second stage of labor
Correct Answer: B
Explanation: The patient is in the active phase of the first stage of labor, characterized by
cervical dilation from 4-7 cm, effacement of 80-100%, and contractions occurring every 2-5
minutes, lasting 45-60 seconds, with moderate to strong intensity. The latent phase is 0-3 cm,
transition is 8-10 cm, and the second stage begins at full dilation.
3. A 25-year-old G1P0 at 40 weeks gestation is in active labor. Her cervix is 6 cm dilated, 100%
effaced, and the presenting part is at 0 station. The fetal heart rate tracing shows a baseline
of 130 bpm, moderate variability, and early decelerations with each contraction. What is the
most appropriate nursing action?
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A. Prepare for immediate cesarean delivery
B. Administer oxygen at 10 L/min via non-rebreather mask
C. Continue to monitor and document the fetal heart rate pattern
D. Notify the provider of non-reassuring fetal status
Correct Answer: C
Explanation: Early decelerations are a benign, reassuring fetal heart rate pattern caused by
head compression during contractions. They mirror the contraction and indicate a well-
oxygenated fetus. No intervention is needed; the nurse should continue to monitor and
document the pattern. Options A, B, and D are appropriate for non-reassuring patterns such as
late or variable decelerations.
4. A 30-year-old G2P1 at 36 weeks gestation presents with a blood pressure of 158/96 mmHg,
2+ proteinuria, and complaints of a headache and blurred vision. Which of the following
medications should the nurse anticipate administering first?
A. Labetalol 20 mg IV push
B. Magnesium sulfate 4 g IV bolus
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C. Nifedipine 10 mg orally
D. Hydralazine 5 mg IV push
Correct Answer: B
Explanation: The patient is exhibiting signs of severe preeclampsia with headache and
blurred vision, indicating central nervous system involvement. Magnesium sulfate is the first-line
medication to prevent seizures (eclampsia) in patients with severe preeclampsia.
Antihypertensives such as labetalol, nifedipine, or hydralazine are used for blood pressure
control but are secondary to seizure prophylaxis in this scenario.
5. A 22-year-old primigravida at 41 weeks gestation is receiving an oxytocin infusion for
induction of labor. The nurse notes that the patient is having contractions every 1.5 minutes,
lasting 90 seconds, and the fetal heart rate shows late decelerations. What is the priority
nursing action?
A. Decrease the oxytocin infusion rate
B. Increase the oxytocin infusion rate
C. Position the patient on her left side
D. Administer terbutaline 0.25 mg subcutaneously
