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NURS 5434 Family III UTA Final Exam Study Guide
| 100% Pass Guaranteed | Graded A+
Question 1
A nurse is caring for a primigravida at 39 weeks gestation who is in active labor. The patient's
membranes rupture spontaneously and the amniotic fluid is meconium-stained. What is the
priority nursing action?
A. Administer oxytocin to augment labor
B. Prepare for immediate cesarean section
C. Assess fetal heart rate and variability
D. Notify the neonatology team for delivery
☑ Correct Answer: C
☑ Explanation: The priority is to assess fetal heart rate and variability. Meconium-stained
amniotic fluid can indicate fetal distress, and the fetus may be compromised. The presence of
meconium increases the risk of meconium aspiration syndrome. While notifying the neonatology
team and preparing for possible interventions are important, the initial action must be to assess
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fetal well-being. Administering oxytocin (A) could worsen fetal distress. Immediate cesarean (B)
is not indicated without further assessment.
Question 2
A postpartum patient who had a vaginal delivery 2 hours ago has a fundus that is boggy,
deviated to the right, and located 2 cm above the umbilicus. She has saturated one perineal pad
in 15 minutes. What is the priority nursing intervention?
A. Massage the fundus and assist the patient to void
B. Administer oxytocin as ordered
C. Assess vital signs and notify the healthcare provider
D. Document the findings and continue to monitor
☑ Correct Answer: A
☑ Explanation: A boggy, deviated fundus above the umbilicus with heavy bleeding is
classic for uterine atony, often caused by a distended bladder. The priority is to massage the
fundus to stimulate uterine contraction and assist the patient to void to empty the bladder,
which allows the uterus to contract effectively. Administering oxytocin (B) would be appropriate
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but only after the fundus is massaged and the bladder is emptied. Notifying the provider (C) is
important but not the first action. Continuing to monitor (D) without intervening is unsafe.
Question 3
A patient at 34 weeks gestation presents with a blood pressure of 160/100 mmHg, 3+
proteinuria, and complaints of a severe headache and epigastric pain. Which condition is the
patient most likely experiencing?
A. Gestational hypertension
B. Preeclampsia with severe features
C. Chronic hypertension
D. Eclampsia
☑ Correct Answer: B
☑ Explanation: The patient meets the criteria for preeclampsia with severe features, which
includes blood pressure ≥ 160/110 mmHg, proteinuria ≥ 3+, and symptoms of severe headache
and epigastric pain (which may indicate hepatic involvement). Gestational hypertension (A)
would not have proteinuria or severe features. Chronic hypertension (C) is pre-existing.
Eclampsia (D) would include seizure activity, which is not mentioned in the scenario.
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Question 4
A nurse is providing teaching to a patient with gestational diabetes mellitus (GDM). Which
statement by the patient indicates a need for further teaching?
A. "I need to check my blood glucose levels four times a day."
B. "I should avoid all carbohydrates in my diet."
C. "I will report any signs of hypoglycemia to my provider."
D. "Exercise can help control my blood glucose levels."
☑ Correct Answer: B
☑ Explanation: Patients with GDM should not avoid all carbohydrates, as carbohydrates
are essential for fetal growth and maternal energy. The focus should be on carbohydrate
counting and distribution throughout the day. Options A, C, and D are all correct statements
regarding GDM management. Option B indicates a need for further teaching about balanced
nutrition.
Question 5
A patient is 1 day postpartum after a cesarean section and reports severe, sharp pain in her
NURS 5434 Family III UTA Final Exam Study Guide
| 100% Pass Guaranteed | Graded A+
Question 1
A nurse is caring for a primigravida at 39 weeks gestation who is in active labor. The patient's
membranes rupture spontaneously and the amniotic fluid is meconium-stained. What is the
priority nursing action?
A. Administer oxytocin to augment labor
B. Prepare for immediate cesarean section
C. Assess fetal heart rate and variability
D. Notify the neonatology team for delivery
☑ Correct Answer: C
☑ Explanation: The priority is to assess fetal heart rate and variability. Meconium-stained
amniotic fluid can indicate fetal distress, and the fetus may be compromised. The presence of
meconium increases the risk of meconium aspiration syndrome. While notifying the neonatology
team and preparing for possible interventions are important, the initial action must be to assess
,2
fetal well-being. Administering oxytocin (A) could worsen fetal distress. Immediate cesarean (B)
is not indicated without further assessment.
Question 2
A postpartum patient who had a vaginal delivery 2 hours ago has a fundus that is boggy,
deviated to the right, and located 2 cm above the umbilicus. She has saturated one perineal pad
in 15 minutes. What is the priority nursing intervention?
A. Massage the fundus and assist the patient to void
B. Administer oxytocin as ordered
C. Assess vital signs and notify the healthcare provider
D. Document the findings and continue to monitor
☑ Correct Answer: A
☑ Explanation: A boggy, deviated fundus above the umbilicus with heavy bleeding is
classic for uterine atony, often caused by a distended bladder. The priority is to massage the
fundus to stimulate uterine contraction and assist the patient to void to empty the bladder,
which allows the uterus to contract effectively. Administering oxytocin (B) would be appropriate
,3
but only after the fundus is massaged and the bladder is emptied. Notifying the provider (C) is
important but not the first action. Continuing to monitor (D) without intervening is unsafe.
Question 3
A patient at 34 weeks gestation presents with a blood pressure of 160/100 mmHg, 3+
proteinuria, and complaints of a severe headache and epigastric pain. Which condition is the
patient most likely experiencing?
A. Gestational hypertension
B. Preeclampsia with severe features
C. Chronic hypertension
D. Eclampsia
☑ Correct Answer: B
☑ Explanation: The patient meets the criteria for preeclampsia with severe features, which
includes blood pressure ≥ 160/110 mmHg, proteinuria ≥ 3+, and symptoms of severe headache
and epigastric pain (which may indicate hepatic involvement). Gestational hypertension (A)
would not have proteinuria or severe features. Chronic hypertension (C) is pre-existing.
Eclampsia (D) would include seizure activity, which is not mentioned in the scenario.
, 4
Question 4
A nurse is providing teaching to a patient with gestational diabetes mellitus (GDM). Which
statement by the patient indicates a need for further teaching?
A. "I need to check my blood glucose levels four times a day."
B. "I should avoid all carbohydrates in my diet."
C. "I will report any signs of hypoglycemia to my provider."
D. "Exercise can help control my blood glucose levels."
☑ Correct Answer: B
☑ Explanation: Patients with GDM should not avoid all carbohydrates, as carbohydrates
are essential for fetal growth and maternal energy. The focus should be on carbohydrate
counting and distribution throughout the day. Options A, C, and D are all correct statements
regarding GDM management. Option B indicates a need for further teaching about balanced
nutrition.
Question 5
A patient is 1 day postpartum after a cesarean section and reports severe, sharp pain in her
