MATERNAL-CHILD NURSING EXAM 3
QUESTIONS AND ANSWERS
1. A nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. Which of
the following findings should the nurse identify as a priority to report to the provider?
A. Urinary output of 20 mL/hr
B. Deep tendon reflexes of 2+
C. Respiratory rate of 14/min
D. Blood pressure of 150/95 mmHg
Answer: A
Conceptual Explanation: Magnesium sulfate is excreted by the kidneys. Urinary output
less than 30 mL/hr can lead to magnesium toxicity. DTR of 2+ and RR of 14 are normal
findings.
2. Which of the following fetal heart rate patterns should the nurse identify as indicating
uteroplacental insufficiency?
A. Late decelerations
B. Variable decelerations
,C. Early decelerations
D. Accelerations
Answer: A
Conceptual Explanation: Late decelerations are caused by uteroplacental insufficiency
and require immediate intervention. Early decelerations are head compression; variables
are cord compression.
3. A nurse is assessing a newborn 1 minute after birth and notes a heart rate of 110/min, a
weak cry, some flexion of extremities, grimacing, and a pink body with blue extremities.
What is the APGAR score?
A. 5
B. 6
C. 7
D. 8
Answer: B
Conceptual Explanation: HR > 100 (2), Weak cry (1), Some flexion (1), Grimace (1),
Acrocyanosis (1). Total = 6.
4. A client at 34 weeks of gestation presents with painless, bright red vaginal bleeding. Which
of the following conditions should the nurse suspect?
A. Placenta previa
, B. Abruptio placentae
C. Uterine rupture
D. Preterm labor
Answer: A
Conceptual Explanation: Painless, bright red bleeding is the hallmark of placenta previa.
Abruptio placentae typically presents with painful, dark red bleeding and a board-like
abdomen.
5. Which of the following medications is administered to a newborn to prevent ophthalmia
neonatorum caused by Neisseria gonorrhoeae?
A. Erythromycin ointment
B. Hepatitis B vaccine
C. Vitamin K
D. Gentamicin
Answer: A
Conceptual Explanation: Erythromycin ophthalmic ointment is mandated by law to
prevent blindness caused by gonorrhea or chlamydia contracted during birth.
6. A nurse is caring for a client in the first stage of labor. The nurse notes variable
decelerations on the fetal monitor. Which action should the nurse take first?
A. Increase the IV fluid rate
QUESTIONS AND ANSWERS
1. A nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. Which of
the following findings should the nurse identify as a priority to report to the provider?
A. Urinary output of 20 mL/hr
B. Deep tendon reflexes of 2+
C. Respiratory rate of 14/min
D. Blood pressure of 150/95 mmHg
Answer: A
Conceptual Explanation: Magnesium sulfate is excreted by the kidneys. Urinary output
less than 30 mL/hr can lead to magnesium toxicity. DTR of 2+ and RR of 14 are normal
findings.
2. Which of the following fetal heart rate patterns should the nurse identify as indicating
uteroplacental insufficiency?
A. Late decelerations
B. Variable decelerations
,C. Early decelerations
D. Accelerations
Answer: A
Conceptual Explanation: Late decelerations are caused by uteroplacental insufficiency
and require immediate intervention. Early decelerations are head compression; variables
are cord compression.
3. A nurse is assessing a newborn 1 minute after birth and notes a heart rate of 110/min, a
weak cry, some flexion of extremities, grimacing, and a pink body with blue extremities.
What is the APGAR score?
A. 5
B. 6
C. 7
D. 8
Answer: B
Conceptual Explanation: HR > 100 (2), Weak cry (1), Some flexion (1), Grimace (1),
Acrocyanosis (1). Total = 6.
4. A client at 34 weeks of gestation presents with painless, bright red vaginal bleeding. Which
of the following conditions should the nurse suspect?
A. Placenta previa
, B. Abruptio placentae
C. Uterine rupture
D. Preterm labor
Answer: A
Conceptual Explanation: Painless, bright red bleeding is the hallmark of placenta previa.
Abruptio placentae typically presents with painful, dark red bleeding and a board-like
abdomen.
5. Which of the following medications is administered to a newborn to prevent ophthalmia
neonatorum caused by Neisseria gonorrhoeae?
A. Erythromycin ointment
B. Hepatitis B vaccine
C. Vitamin K
D. Gentamicin
Answer: A
Conceptual Explanation: Erythromycin ophthalmic ointment is mandated by law to
prevent blindness caused by gonorrhea or chlamydia contracted during birth.
6. A nurse is caring for a client in the first stage of labor. The nurse notes variable
decelerations on the fetal monitor. Which action should the nurse take first?
A. Increase the IV fluid rate
