NUR 231 Exam 4 – Maternal Nursing Comprehensive Quiz 20… 2026 Update • Verified Answers
✓ VERIFIED • 2026 UPDATE • 100% ACCURATE
NUR 231 Exam 4 – Maternal Nursing Comprehensive
Quiz 2026 UPDATE
Actual Exam Questions & Verified Answers
with Detailed Rationales
Document Type: Exam (Elaborations)
Academic Year:
Total Questions: 50 Multiple Choice
Includes: Correct Answers + Full Rationales
Status: Verified & Updated for 2026
Exam (Elaborations) • Actual Questions & Rationales Page 1
,NUR 231 Exam 4 – Maternal Nursing Comprehensive Quiz 20… 2026 Update • Verified Answers
Questions & Verified Answers
1. A nurse is caring for a client in the second stage of labor. Which of the following
manifestations should the nurse expect?
A. The client is quiet and follows instructions easily.
B. The cervix is dilated from 0 to 3 cm.
C. The client experiences a strong urge to bear down.
D. The placental separation occurs.
Answer: C
Rationale: The second stage of labor begins with full cervical dilation (10 cm) and ends with the birth of the
baby; the primary characteristic is the urge to push or bear down. Recognizing this principle allows the nurse to
prioritize care, anticipate complications, and provide accurate patient education.
2. When monitoring a fetal heart rate (FHR), the nurse notes late decelerations. Which action
should the nurse take first?
A. Increase the rate of oxytocin infusion.
B. Place the client in a supine position.
C. Perform a vaginal exam to check for cord prolapse.
D. Administer oxygen via a non-rebreather mask at 8-10 L/min.
Answer: D
Rationale: Late decelerations indicate uteroplacental insufficiency. Immediate interventions include
repositioning the patient to the side, discontinuing oxytocin, and administering oxygen to improve fetal
oxygenation. Recognizing this principle allows the nurse to prioritize care, anticipate complications, and provide
accurate patient education.
3. A client at 32 weeks gestation presents with painless, bright red vaginal bleeding. Which
condition should the nurse suspect?
A. Abruptio placentae
B. Molar pregnancy
C. Ectopic pregnancy
D. Placenta previa
Answer: D
Rationale: Placenta previa is characterized by painless, bright red vaginal bleeding during the second or third
trimester. Abruptio placentae usually involves painful, dark red bleeding. Exam questions often test the ability to
distinguish this concept from closely related distractors, making a clear rationale essential for mastery.
Exam (Elaborations) • Actual Questions & Rationales Page 2
, NUR 231 Exam 4 – Maternal Nursing Comprehensive Quiz 20… 2026 Update • Verified Answers
4. A nurse is monitoring a client receiving magnesium sulfate for preeclampsia. Which finding
is the most critical to report to the provider?
A. Feeling of warmth and flushing
B. Respiratory rate of 10/min
C. Urinary output of 40 mL/hr
D. Deep tendon reflexes of 2+
Answer: B
Rationale: Magnesium sulfate toxicity causes central nervous system depression, leading to respiratory
depression (less than 12/min) and loss of deep tendon reflexes. Applying this knowledge in clinical settings
supports safe, evidence-based practice and improves patient outcomes. This is an important clinical concept
because selecting the correct answer (B) requires understanding both the pathophysiology and the practical
nursing implications.
5. One hour after delivery, a nurse finds the client’s fundus to be boggy and displaced to the
right. What is the priority nursing action?
A. Massage the fundus until firm.
B. Notify the provider immediately.
C. Increase the IV fluid rate.
D. Assist the client to the bathroom to void.
Answer: D
Rationale: A fundus displaced to the right usually indicates a distended bladder, which prevents the uterus
from contracting. The priority is to empty the bladder. Exam questions often test the ability to distinguish this
concept from closely related distractors, making a clear rationale essential for mastery. Applying this knowledge
in clinical settings supports safe, evidence-based practice and improves patient outcomes.
6. Which APGAR score at 1 minute would require immediate resuscitation?
A. 9
B. 7
C. 5
D. 2
Answer: D
Rationale: An APGAR score of 0-3 indicates severe distress and requires immediate resuscitation. 4-6
indicates moderate difficulty, and 7-10 is within normal limits. Exam questions often test the ability to distinguish
this concept from closely related distractors, making a clear rationale essential for mastery. Applying this
knowledge in clinical settings supports safe, evidence-based practice and improves patient outcomes.
Exam (Elaborations) • Actual Questions & Rationales Page 3
✓ VERIFIED • 2026 UPDATE • 100% ACCURATE
NUR 231 Exam 4 – Maternal Nursing Comprehensive
Quiz 2026 UPDATE
Actual Exam Questions & Verified Answers
with Detailed Rationales
Document Type: Exam (Elaborations)
Academic Year:
Total Questions: 50 Multiple Choice
Includes: Correct Answers + Full Rationales
Status: Verified & Updated for 2026
Exam (Elaborations) • Actual Questions & Rationales Page 1
,NUR 231 Exam 4 – Maternal Nursing Comprehensive Quiz 20… 2026 Update • Verified Answers
Questions & Verified Answers
1. A nurse is caring for a client in the second stage of labor. Which of the following
manifestations should the nurse expect?
A. The client is quiet and follows instructions easily.
B. The cervix is dilated from 0 to 3 cm.
C. The client experiences a strong urge to bear down.
D. The placental separation occurs.
Answer: C
Rationale: The second stage of labor begins with full cervical dilation (10 cm) and ends with the birth of the
baby; the primary characteristic is the urge to push or bear down. Recognizing this principle allows the nurse to
prioritize care, anticipate complications, and provide accurate patient education.
2. When monitoring a fetal heart rate (FHR), the nurse notes late decelerations. Which action
should the nurse take first?
A. Increase the rate of oxytocin infusion.
B. Place the client in a supine position.
C. Perform a vaginal exam to check for cord prolapse.
D. Administer oxygen via a non-rebreather mask at 8-10 L/min.
Answer: D
Rationale: Late decelerations indicate uteroplacental insufficiency. Immediate interventions include
repositioning the patient to the side, discontinuing oxytocin, and administering oxygen to improve fetal
oxygenation. Recognizing this principle allows the nurse to prioritize care, anticipate complications, and provide
accurate patient education.
3. A client at 32 weeks gestation presents with painless, bright red vaginal bleeding. Which
condition should the nurse suspect?
A. Abruptio placentae
B. Molar pregnancy
C. Ectopic pregnancy
D. Placenta previa
Answer: D
Rationale: Placenta previa is characterized by painless, bright red vaginal bleeding during the second or third
trimester. Abruptio placentae usually involves painful, dark red bleeding. Exam questions often test the ability to
distinguish this concept from closely related distractors, making a clear rationale essential for mastery.
Exam (Elaborations) • Actual Questions & Rationales Page 2
, NUR 231 Exam 4 – Maternal Nursing Comprehensive Quiz 20… 2026 Update • Verified Answers
4. A nurse is monitoring a client receiving magnesium sulfate for preeclampsia. Which finding
is the most critical to report to the provider?
A. Feeling of warmth and flushing
B. Respiratory rate of 10/min
C. Urinary output of 40 mL/hr
D. Deep tendon reflexes of 2+
Answer: B
Rationale: Magnesium sulfate toxicity causes central nervous system depression, leading to respiratory
depression (less than 12/min) and loss of deep tendon reflexes. Applying this knowledge in clinical settings
supports safe, evidence-based practice and improves patient outcomes. This is an important clinical concept
because selecting the correct answer (B) requires understanding both the pathophysiology and the practical
nursing implications.
5. One hour after delivery, a nurse finds the client’s fundus to be boggy and displaced to the
right. What is the priority nursing action?
A. Massage the fundus until firm.
B. Notify the provider immediately.
C. Increase the IV fluid rate.
D. Assist the client to the bathroom to void.
Answer: D
Rationale: A fundus displaced to the right usually indicates a distended bladder, which prevents the uterus
from contracting. The priority is to empty the bladder. Exam questions often test the ability to distinguish this
concept from closely related distractors, making a clear rationale essential for mastery. Applying this knowledge
in clinical settings supports safe, evidence-based practice and improves patient outcomes.
6. Which APGAR score at 1 minute would require immediate resuscitation?
A. 9
B. 7
C. 5
D. 2
Answer: D
Rationale: An APGAR score of 0-3 indicates severe distress and requires immediate resuscitation. 4-6
indicates moderate difficulty, and 7-10 is within normal limits. Exam questions often test the ability to distinguish
this concept from closely related distractors, making a clear rationale essential for mastery. Applying this
knowledge in clinical settings supports safe, evidence-based practice and improves patient outcomes.
Exam (Elaborations) • Actual Questions & Rationales Page 3
