NUR 230 MATERNAL NURSING EXAM 1–4 NCLEX- C. Hemoglobin 12 g/dL
STYLE FOR GALEN COLLEGE OF NURSING ACTUAL D. Weight gain of 2 lb since last month
QUESTIONS AND ANSWERS - LATEST AND Rationale: Preexisting diabetes places the pregnancy at high risk and
COMPLETE UPDATE WITH VERIFIED SOLUTIONS – requires early and intensive management.
ASSURED PASS WITH ISTANT DOWNLOAD PDF.
4. A nurse is reviewing lab results of a pregnant client who is Rh-negative.
1. A nurse is teaching a client who is planning pregnancy about folic acid Which result is most concerning?
supplementation. Which statement by the client indicates correct A. Negative antibody screen
understanding? B. Hematocrit 34%
A. Folic acid prevents anemia during pregnancy C. Positive indirect Coombs test
B. Folic acid reduces the risk of neural tube defects D. Platelet count 200,000/mm³
C. Folic acid improves fetal lung maturity Rationale: A positive indirect Coombs test indicates maternal sensitization,
D. Folic acid prevents postpartum hemorrhage which can lead to hemolytic disease of the fetus/newborn.
Rationale: Adequate folic acid intake before conception and during early 5. Which assessment finding confirms uterine contractions rather than Braxton
pregnancy significantly reduces the risk of neural tube defects such as Hicks contractions?
spina bifida and anencephaly. A. Irregular frequency
2. A pregnant client at 10 weeks’ gestation asks why nausea and vomiting are B. Progressive cervical dilation
most severe in the first trimester. The nurse explains this is primarily due to: C. Decrease with ambulation
A. Increased progesterone levels D. Mild discomfort
B. Rapid rise in human chorionic gonadotropin (hCG) Rationale: True labor contractions cause progressive cervical dilation and
C. Increased estrogen metabolism effacement.
D. Decreased gastric motility 6. The nurse teaches a pregnant client about physiologic anemia of pregnancy.
Rationale: hCG peaks in the first trimester and is strongly associated with Which explanation is correct?
nausea and vomiting of pregnancy. A. Iron stores are depleted
3. Which finding during the first prenatal visit requires immediate follow-up by B. Plasma volume increases more than red blood cell mass
the nurse? C. Red blood cells are destroyed faster
A. Blood pressure 110/70 mmHg D. Bone marrow suppression occurs
B. History of insulin-dependent diabetes mellitus
, Rationale: Hemodilution occurs because plasma volume expands more 10.The nurse identifies that a client understands signs of preeclampsia when the
than RBC mass, causing physiologic anemia. client reports which symptom?
7. A pregnant client at 28 weeks’ gestation receives Rho(D) immune globulin. A. Increased appetite
The nurse explains this medication works by: B. Mild ankle edema
A. Stimulating maternal antibody production C. Severe headache unrelieved by acetaminophen
B. Preventing maternal sensitization to Rh-positive cells D. Frequent urination
C. Treating fetal anemia Rationale: Severe headache is a warning sign of preeclampsia and
D. Increasing fetal red blood cell production requires immediate evaluation.
Rationale: Rho(D) immune globulin prevents maternal antibody 11.A pregnant client with gestational diabetes is taught home glucose
formation against Rh-positive fetal blood cells. monitoring. Which value requires immediate reporting?
8. A nurse is assessing a client in the second trimester. Which discomfort is A. Fasting glucose 88 mg/dL
expected? B. 2-hour postprandial glucose 160 mg/dL
A. Urinary frequency C. Bedtime glucose 95 mg/dL
B. Round ligament pain D. Pre-meal glucose 90 mg/dL
C. Nausea and vomiting Rationale: Postprandial glucose levels above target increase fetal risk and
D. Ptyalism must be reported.
Rationale: Round ligament pain commonly occurs in the second trimester 12.The nurse assesses fundal height in a client at 24 weeks’ gestation. Which
due to uterine growth. finding is expected?
9. Which intervention is most appropriate for a client experiencing supine A. At the symphysis pubis
hypotensive syndrome? B. 2 cm above the umbilicus
A. Increase IV fluids C. At the level of the umbilicus
B. Position the client in a left lateral position D. Halfway between umbilicus and xiphoid
C. Apply oxygen by mask Rationale: At 20–24 weeks, the fundus is typically at the level of the
D. Administer antihypertensive medication umbilicus.
Rationale: Left lateral positioning relieves vena cava compression and 13.A nurse is caring for a client in active labor. Which finding indicates the
improves venous return. transition phase?
A. Cervical dilation of 5 cm
, B. Contractions every 5 minutes 17.A postpartum client reports heavy bleeding one hour after delivery. The
C. Increased irritability and urge to push uterus is boggy. What is the nurse’s first action?
D. Mild contraction intensity A. Administer oxytocin
Rationale: Transition is characterized by intense contractions, irritability, B. Perform fundal massage
and an urge to push. C. Notify the provider
14.Which fetal heart rate pattern requires immediate intervention? D. Prepare for surgery
A. Moderate variability Rationale: Uterine atony is the most common cause of postpartum
B. Accelerations with movement hemorrhage; fundal massage is the first intervention.
C. Late decelerations 18.Which client is at highest risk for postpartum hemorrhage?
D. Baseline 130 bpm A. Primigravida
Rationale: Late decelerations indicate uteroplacental insufficiency and B. Term vaginal delivery
require prompt action. C. Prolonged labor with oxytocin use
15.The nurse prepares to administer oxytocin. Which assessment is priority? D. Newborn weight 3,200 g
A. Maternal temperature Rationale: Uterine fatigue from prolonged labor and oxytocin increases
B. Cervical dilation hemorrhage risk.
C. Uterine contraction pattern 19.The nurse teaches a postpartum client about lochia. Which statement
D. Fetal weight estimate indicates understanding?
Rationale: Oxytocin can cause uterine tachysystole, so contraction pattern A. Lochia rubra lasts 6 weeks
must be closely monitored. B. Lochia serosa is bright red
16.Which finding indicates adequate placental perfusion? C. Lochia alba is white or yellowish
A. Fetal tachycardia D. Lochia should stop within 3 days
B. Moderate fetal heart rate variability Rationale: Lochia alba is pale and occurs last as healing progresses.
C. Recurrent variable decelerations 20.A breastfeeding client asks how often to feed the newborn. The nurse
D. Maternal hypotension responds:
Rationale: Moderate variability reflects adequate fetal oxygenation and A. Every 6 hours
placental perfusion. B. On a strict schedule
C. On demand, about 8–12 times per day
STYLE FOR GALEN COLLEGE OF NURSING ACTUAL D. Weight gain of 2 lb since last month
QUESTIONS AND ANSWERS - LATEST AND Rationale: Preexisting diabetes places the pregnancy at high risk and
COMPLETE UPDATE WITH VERIFIED SOLUTIONS – requires early and intensive management.
ASSURED PASS WITH ISTANT DOWNLOAD PDF.
4. A nurse is reviewing lab results of a pregnant client who is Rh-negative.
1. A nurse is teaching a client who is planning pregnancy about folic acid Which result is most concerning?
supplementation. Which statement by the client indicates correct A. Negative antibody screen
understanding? B. Hematocrit 34%
A. Folic acid prevents anemia during pregnancy C. Positive indirect Coombs test
B. Folic acid reduces the risk of neural tube defects D. Platelet count 200,000/mm³
C. Folic acid improves fetal lung maturity Rationale: A positive indirect Coombs test indicates maternal sensitization,
D. Folic acid prevents postpartum hemorrhage which can lead to hemolytic disease of the fetus/newborn.
Rationale: Adequate folic acid intake before conception and during early 5. Which assessment finding confirms uterine contractions rather than Braxton
pregnancy significantly reduces the risk of neural tube defects such as Hicks contractions?
spina bifida and anencephaly. A. Irregular frequency
2. A pregnant client at 10 weeks’ gestation asks why nausea and vomiting are B. Progressive cervical dilation
most severe in the first trimester. The nurse explains this is primarily due to: C. Decrease with ambulation
A. Increased progesterone levels D. Mild discomfort
B. Rapid rise in human chorionic gonadotropin (hCG) Rationale: True labor contractions cause progressive cervical dilation and
C. Increased estrogen metabolism effacement.
D. Decreased gastric motility 6. The nurse teaches a pregnant client about physiologic anemia of pregnancy.
Rationale: hCG peaks in the first trimester and is strongly associated with Which explanation is correct?
nausea and vomiting of pregnancy. A. Iron stores are depleted
3. Which finding during the first prenatal visit requires immediate follow-up by B. Plasma volume increases more than red blood cell mass
the nurse? C. Red blood cells are destroyed faster
A. Blood pressure 110/70 mmHg D. Bone marrow suppression occurs
B. History of insulin-dependent diabetes mellitus
, Rationale: Hemodilution occurs because plasma volume expands more 10.The nurse identifies that a client understands signs of preeclampsia when the
than RBC mass, causing physiologic anemia. client reports which symptom?
7. A pregnant client at 28 weeks’ gestation receives Rho(D) immune globulin. A. Increased appetite
The nurse explains this medication works by: B. Mild ankle edema
A. Stimulating maternal antibody production C. Severe headache unrelieved by acetaminophen
B. Preventing maternal sensitization to Rh-positive cells D. Frequent urination
C. Treating fetal anemia Rationale: Severe headache is a warning sign of preeclampsia and
D. Increasing fetal red blood cell production requires immediate evaluation.
Rationale: Rho(D) immune globulin prevents maternal antibody 11.A pregnant client with gestational diabetes is taught home glucose
formation against Rh-positive fetal blood cells. monitoring. Which value requires immediate reporting?
8. A nurse is assessing a client in the second trimester. Which discomfort is A. Fasting glucose 88 mg/dL
expected? B. 2-hour postprandial glucose 160 mg/dL
A. Urinary frequency C. Bedtime glucose 95 mg/dL
B. Round ligament pain D. Pre-meal glucose 90 mg/dL
C. Nausea and vomiting Rationale: Postprandial glucose levels above target increase fetal risk and
D. Ptyalism must be reported.
Rationale: Round ligament pain commonly occurs in the second trimester 12.The nurse assesses fundal height in a client at 24 weeks’ gestation. Which
due to uterine growth. finding is expected?
9. Which intervention is most appropriate for a client experiencing supine A. At the symphysis pubis
hypotensive syndrome? B. 2 cm above the umbilicus
A. Increase IV fluids C. At the level of the umbilicus
B. Position the client in a left lateral position D. Halfway between umbilicus and xiphoid
C. Apply oxygen by mask Rationale: At 20–24 weeks, the fundus is typically at the level of the
D. Administer antihypertensive medication umbilicus.
Rationale: Left lateral positioning relieves vena cava compression and 13.A nurse is caring for a client in active labor. Which finding indicates the
improves venous return. transition phase?
A. Cervical dilation of 5 cm
, B. Contractions every 5 minutes 17.A postpartum client reports heavy bleeding one hour after delivery. The
C. Increased irritability and urge to push uterus is boggy. What is the nurse’s first action?
D. Mild contraction intensity A. Administer oxytocin
Rationale: Transition is characterized by intense contractions, irritability, B. Perform fundal massage
and an urge to push. C. Notify the provider
14.Which fetal heart rate pattern requires immediate intervention? D. Prepare for surgery
A. Moderate variability Rationale: Uterine atony is the most common cause of postpartum
B. Accelerations with movement hemorrhage; fundal massage is the first intervention.
C. Late decelerations 18.Which client is at highest risk for postpartum hemorrhage?
D. Baseline 130 bpm A. Primigravida
Rationale: Late decelerations indicate uteroplacental insufficiency and B. Term vaginal delivery
require prompt action. C. Prolonged labor with oxytocin use
15.The nurse prepares to administer oxytocin. Which assessment is priority? D. Newborn weight 3,200 g
A. Maternal temperature Rationale: Uterine fatigue from prolonged labor and oxytocin increases
B. Cervical dilation hemorrhage risk.
C. Uterine contraction pattern 19.The nurse teaches a postpartum client about lochia. Which statement
D. Fetal weight estimate indicates understanding?
Rationale: Oxytocin can cause uterine tachysystole, so contraction pattern A. Lochia rubra lasts 6 weeks
must be closely monitored. B. Lochia serosa is bright red
16.Which finding indicates adequate placental perfusion? C. Lochia alba is white or yellowish
A. Fetal tachycardia D. Lochia should stop within 3 days
B. Moderate fetal heart rate variability Rationale: Lochia alba is pale and occurs last as healing progresses.
C. Recurrent variable decelerations 20.A breastfeeding client asks how often to feed the newborn. The nurse
D. Maternal hypotension responds:
Rationale: Moderate variability reflects adequate fetal oxygenation and A. Every 6 hours
placental perfusion. B. On a strict schedule
C. On demand, about 8–12 times per day
