NUR2513 MATERNAL-CHILD NURSING
FINAL EXAM QUESTIONS AND
ANSWERS
1. A nurse is monitoring a client in labor who has been diagnosed with severe preeclampsia.
Which assessment finding should the nurse prioritize as a sign of impending seizure?
A. Increased urine output and decreased protein
B. Epigastric pain and frontal headache
C. Bradycardia and decreased blood pressure
D. Generalized edema in the lower extremities
Answer: B
Conceptual Explanation: Epigastric pain and a severe frontal headache are signs of
central nervous system irritability and hepatic involvement, often preceding a tonic-clonic
seizure (eclampsia).
2. A patient at 32 weeks gestation is receiving Magnesium Sulfate for preterm labor. Which
finding would require the nurse to immediately discontinue the infusion?
A. Fetal heart rate of 140 bpm
,B. Flushing and a feeling of warmth
C. Absent deep tendon reflexes
D. Respiratory rate of 16 breaths/min
Answer: C
Conceptual Explanation: Loss of deep tendon reflexes is an early sign of magnesium
toxicity. The infusion must be stopped to prevent respiratory depression and cardiac
arrest.
3. When interpreting a fetal heart rate (FHR) tracing, the nurse notes late decelerations.
Which underlying condition is the most likely cause?
A. Uteroplacental insufficiency
B. Umbilical cord compression
C. Fetal head compression
D. Maternal narcotic administration
Answer: A
Conceptual Explanation: Late decelerations are caused by uteroplacental insufficiency,
where the fetus is not receiving adequate oxygen during and after contractions.
, 4. A nurse is caring for a client in the second stage of labor. The nurse notes the fetal head is
visible at the vaginal opening but retreats between contractions. What is the correct term for
this?
A. Crowning
B. Engagement
C. Floating
D. Restitution
Answer: A
Conceptual Explanation: Crowning occurs when the widest part of the fetal head is visible
at the vaginal opening and does not retreat between contractions; however, initial
visualization is the start of this process.
5. A postpartum nurse is assessing a client 4 hours after a vaginal delivery. The fundus is firm,
2 fingerbreadths above the umbilicus, and deviated to the right. What is the priority nursing
action?
A. Massage the fundus vigorously
B. Notify the primary care provider
C. Assist the client to empty her bladder
D. Administer an oxytocic medication
Answer: C
FINAL EXAM QUESTIONS AND
ANSWERS
1. A nurse is monitoring a client in labor who has been diagnosed with severe preeclampsia.
Which assessment finding should the nurse prioritize as a sign of impending seizure?
A. Increased urine output and decreased protein
B. Epigastric pain and frontal headache
C. Bradycardia and decreased blood pressure
D. Generalized edema in the lower extremities
Answer: B
Conceptual Explanation: Epigastric pain and a severe frontal headache are signs of
central nervous system irritability and hepatic involvement, often preceding a tonic-clonic
seizure (eclampsia).
2. A patient at 32 weeks gestation is receiving Magnesium Sulfate for preterm labor. Which
finding would require the nurse to immediately discontinue the infusion?
A. Fetal heart rate of 140 bpm
,B. Flushing and a feeling of warmth
C. Absent deep tendon reflexes
D. Respiratory rate of 16 breaths/min
Answer: C
Conceptual Explanation: Loss of deep tendon reflexes is an early sign of magnesium
toxicity. The infusion must be stopped to prevent respiratory depression and cardiac
arrest.
3. When interpreting a fetal heart rate (FHR) tracing, the nurse notes late decelerations.
Which underlying condition is the most likely cause?
A. Uteroplacental insufficiency
B. Umbilical cord compression
C. Fetal head compression
D. Maternal narcotic administration
Answer: A
Conceptual Explanation: Late decelerations are caused by uteroplacental insufficiency,
where the fetus is not receiving adequate oxygen during and after contractions.
, 4. A nurse is caring for a client in the second stage of labor. The nurse notes the fetal head is
visible at the vaginal opening but retreats between contractions. What is the correct term for
this?
A. Crowning
B. Engagement
C. Floating
D. Restitution
Answer: A
Conceptual Explanation: Crowning occurs when the widest part of the fetal head is visible
at the vaginal opening and does not retreat between contractions; however, initial
visualization is the start of this process.
5. A postpartum nurse is assessing a client 4 hours after a vaginal delivery. The fundus is firm,
2 fingerbreadths above the umbilicus, and deviated to the right. What is the priority nursing
action?
A. Massage the fundus vigorously
B. Notify the primary care provider
C. Assist the client to empty her bladder
D. Administer an oxytocic medication
Answer: C
