NUR2513 Maternal-Child Nursing Final Exam | 2026/2027
Grade A Answers | Evidence-Based Practice | NCLEX-Style Assessment
SECTION 1: ANTEPARTUM & INTRAPARTUM CARE (25 Questions)
Q1. A client at 32 weeks gestation presents with blood pressure 150/98 mmHg, +2
proteinuria, and severe headache. What is the priority nursing action?
A. Administer prescribed antihypertensive medication.
B. Place the client in a left lateral position and notify the provider immediately.
[CORRECT]
C. Start an IV line for fluid administration.
D. Prepare for a non-stress test (NST).
Correct Answer: B
Rationale: This client exhibits severe preeclampsia (BP ≥140/90 with proteinuria and
cerebral symptoms). The immediate priority is maternal safety and placental perfusion.
Left lateral positioning relieves inferior vena cava compression, improving
uteroplacental blood flow by 20-30%. The severe headache indicates potential
impending eclampsia (seizure risk), requiring immediate provider notification for
magnesium sulfate therapy. While antihypertensives (A) and IV access (C) are
important, positioning and notification take precedence. NST (D) is not the priority with
active severe features.
Q2. A pregnant client at 28 weeks asks about fetal movement counting. The nurse
should instruct her to:
A. Count movements for 30 minutes daily; if fewer than 3 movements are felt, call the
provider.
B. Count movements for 1 hour after meals; expect 4-6 movements per hour.
C. Use the "count-to-10" method: note how long it takes to feel 10 movements, usually
less than 2 hours [CORRECT]
D. Fetal movement counting is not necessary until 36 weeks gestation.
,Correct Answer: C
Rationale: The "count-to-10" method (Cardiff or Sadovsky method) is the recommended
approach: the pregnant person notes how long it takes to feel 10 distinct movements,
which should typically occur within 2 hours (often much less). This method is more
reliable than arbitrary time limits or minimum counts. Decreased fetal movement is a
red flag for fetal compromise and requires evaluation. Fetal movement counting begins
in the third trimester (28 weeks), not 36 weeks (D).
Q3. Select all that apply: A client with gestational diabetes mellitus (GDM) at 38 weeks
asks about fetal risks. Which complications are associated with GDM? [Select all that
apply]
A. Macrosomia [CORRECT]
B. Polyhydramnios [CORRECT]
C. Intrauterine growth restriction (IUGR)
D. Neonatal hypoglycemia [CORRECT]
E. Preterm labor
Correct Answers: A, B, D
Rationale: Maternal hyperglycemia causes fetal hyperglycemia, triggering increased
insulin production (fetal hyperinsulinism). This promotes macrosomia (A) and can
cause polyhydramnios (B) due to fetal polyuria. After delivery, neonatal hypoglycemia
(D) occurs when the maternal glucose supply is cut off but fetal insulin remains
elevated. IUGR (C) is more associated with placental insufficiency, not typical GGD.
Preterm labor (E) is not directly caused by GDM, though it may occur with other
complications.
Q4. A client in active labor has a fetal heart rate baseline of 145 bpm with moderate
variability. During contractions, the FHR drops to 110 bpm, returning to baseline by the
end of the contraction. This pattern is:
A. Early decelerations [CORRECT]
B. Late decelerations
C. Variable decelerations
,D. Prolonged decelerations
Correct Answer: A
Rationale: Early decelerations are benign, head compression patterns characterized by:
gradual onset, mirror image of the contraction (nadir at peak contraction), return to
baseline by end of contraction, and no change in variability. They indicate vagal nerve
stimulation from fetal head compression and require no intervention. Late decelerations
(B) are gradual with delayed nadir (after contraction peak), indicating uteroplacental
insufficiency. Variable decelerations (C) are abrupt, variable in shape, indicating cord
compression. Prolonged decelerations (D) last >2 minutes.
Q5. A client at 40 weeks gestation is admitted with ruptured membranes. The nurse
notes meconium-stained amniotic fluid. The priority intervention is:
A. Prepare for immediate cesarean birth.
B. Apply fetal scalp electrode for continuous monitoring.
C. Prepare for possible neonatal resuscitation and notify the neonatal team [CORRECT]
D. Administer oxytocin to expedite delivery.
Correct Answer: C
Rationale: Meconium-stained fluid indicates fetal stress and risk for meconium
aspiration syndrome (MAS) if the fetus gasps in utero or with first breath. The priority is
preparing for neonatal resuscitation (suctioning, positive pressure ventilation if needed)
and notifying the neonatal team. Immediate cesarean (A) is not indicated without fetal
distress. Internal monitoring (B) is contraindicated with ruptured membranes and
possible infection. Oxytocin (D) requires assessment of labor progress and fetal status
first.
Q6. A client receiving magnesium sulfate for preeclampsia has a respiratory rate of 10
breaths/minute, absent deep tendon reflexes, and urine output of 80 mL in 4 hours. The
nurse should:
A. Continue the infusion and increase the maintenance dose.
, B. Stop the infusion immediately and prepare to administer calcium gluconate
[CORRECT]
C. Administer a diuretic to increase urine output.
D. Position the client supine for better respiratory effort.
Correct Answer: B
Rationale: These are signs of magnesium sulfate toxicity: respiratory depression (<12
breaths/min), absent patellar reflexes, and oliguria (<30 mL/hr or 100 mL/4hr). The
antidote is calcium gluconate 1g IV. The infusion must be stopped immediately to
prevent respiratory arrest and cardiac arrest. Continuing (A) would be lethal. Diuretics
(C) worsen magnesium retention. Supine position (D) causes aortocaval compression.
Q7. The nurse is assessing a client at 20 weeks gestation. Which finding requires
immediate follow-up?
A. Fundal height at the umbilicus
B. Fetal heart rate of 150 bpm
C. Blood pressure 142/92 mmHg [CORRECT]
D. Weight gain of 3 pounds since last visit
Correct Answer: C
Rationale: Hypertension in pregnancy (≥140/90) at 20 weeks (before the typical
20-week threshold for gestational hypertension) suggests chronic hypertension or
early-onset preeclampsia, both requiring urgent evaluation. Fundal height at umbilicus
(A) is appropriate for 20 weeks. FHR 150 (B) is normal. Weight gain (D) requires context
but 3 lbs is not immediately concerning.
Q8. A client in the first stage of labor reports severe back pain. Assessment reveals the
fetus is in the occiput posterior (OP) position. Which nursing intervention is most
appropriate?
A. Encourage supine positioning with legs elevated.
B. Apply sacral pressure and encourage hands-and-knees or side-lying positions
[CORRECT]
C. Administer a stat dose of intravenous opioid.
Grade A Answers | Evidence-Based Practice | NCLEX-Style Assessment
SECTION 1: ANTEPARTUM & INTRAPARTUM CARE (25 Questions)
Q1. A client at 32 weeks gestation presents with blood pressure 150/98 mmHg, +2
proteinuria, and severe headache. What is the priority nursing action?
A. Administer prescribed antihypertensive medication.
B. Place the client in a left lateral position and notify the provider immediately.
[CORRECT]
C. Start an IV line for fluid administration.
D. Prepare for a non-stress test (NST).
Correct Answer: B
Rationale: This client exhibits severe preeclampsia (BP ≥140/90 with proteinuria and
cerebral symptoms). The immediate priority is maternal safety and placental perfusion.
Left lateral positioning relieves inferior vena cava compression, improving
uteroplacental blood flow by 20-30%. The severe headache indicates potential
impending eclampsia (seizure risk), requiring immediate provider notification for
magnesium sulfate therapy. While antihypertensives (A) and IV access (C) are
important, positioning and notification take precedence. NST (D) is not the priority with
active severe features.
Q2. A pregnant client at 28 weeks asks about fetal movement counting. The nurse
should instruct her to:
A. Count movements for 30 minutes daily; if fewer than 3 movements are felt, call the
provider.
B. Count movements for 1 hour after meals; expect 4-6 movements per hour.
C. Use the "count-to-10" method: note how long it takes to feel 10 movements, usually
less than 2 hours [CORRECT]
D. Fetal movement counting is not necessary until 36 weeks gestation.
,Correct Answer: C
Rationale: The "count-to-10" method (Cardiff or Sadovsky method) is the recommended
approach: the pregnant person notes how long it takes to feel 10 distinct movements,
which should typically occur within 2 hours (often much less). This method is more
reliable than arbitrary time limits or minimum counts. Decreased fetal movement is a
red flag for fetal compromise and requires evaluation. Fetal movement counting begins
in the third trimester (28 weeks), not 36 weeks (D).
Q3. Select all that apply: A client with gestational diabetes mellitus (GDM) at 38 weeks
asks about fetal risks. Which complications are associated with GDM? [Select all that
apply]
A. Macrosomia [CORRECT]
B. Polyhydramnios [CORRECT]
C. Intrauterine growth restriction (IUGR)
D. Neonatal hypoglycemia [CORRECT]
E. Preterm labor
Correct Answers: A, B, D
Rationale: Maternal hyperglycemia causes fetal hyperglycemia, triggering increased
insulin production (fetal hyperinsulinism). This promotes macrosomia (A) and can
cause polyhydramnios (B) due to fetal polyuria. After delivery, neonatal hypoglycemia
(D) occurs when the maternal glucose supply is cut off but fetal insulin remains
elevated. IUGR (C) is more associated with placental insufficiency, not typical GGD.
Preterm labor (E) is not directly caused by GDM, though it may occur with other
complications.
Q4. A client in active labor has a fetal heart rate baseline of 145 bpm with moderate
variability. During contractions, the FHR drops to 110 bpm, returning to baseline by the
end of the contraction. This pattern is:
A. Early decelerations [CORRECT]
B. Late decelerations
C. Variable decelerations
,D. Prolonged decelerations
Correct Answer: A
Rationale: Early decelerations are benign, head compression patterns characterized by:
gradual onset, mirror image of the contraction (nadir at peak contraction), return to
baseline by end of contraction, and no change in variability. They indicate vagal nerve
stimulation from fetal head compression and require no intervention. Late decelerations
(B) are gradual with delayed nadir (after contraction peak), indicating uteroplacental
insufficiency. Variable decelerations (C) are abrupt, variable in shape, indicating cord
compression. Prolonged decelerations (D) last >2 minutes.
Q5. A client at 40 weeks gestation is admitted with ruptured membranes. The nurse
notes meconium-stained amniotic fluid. The priority intervention is:
A. Prepare for immediate cesarean birth.
B. Apply fetal scalp electrode for continuous monitoring.
C. Prepare for possible neonatal resuscitation and notify the neonatal team [CORRECT]
D. Administer oxytocin to expedite delivery.
Correct Answer: C
Rationale: Meconium-stained fluid indicates fetal stress and risk for meconium
aspiration syndrome (MAS) if the fetus gasps in utero or with first breath. The priority is
preparing for neonatal resuscitation (suctioning, positive pressure ventilation if needed)
and notifying the neonatal team. Immediate cesarean (A) is not indicated without fetal
distress. Internal monitoring (B) is contraindicated with ruptured membranes and
possible infection. Oxytocin (D) requires assessment of labor progress and fetal status
first.
Q6. A client receiving magnesium sulfate for preeclampsia has a respiratory rate of 10
breaths/minute, absent deep tendon reflexes, and urine output of 80 mL in 4 hours. The
nurse should:
A. Continue the infusion and increase the maintenance dose.
, B. Stop the infusion immediately and prepare to administer calcium gluconate
[CORRECT]
C. Administer a diuretic to increase urine output.
D. Position the client supine for better respiratory effort.
Correct Answer: B
Rationale: These are signs of magnesium sulfate toxicity: respiratory depression (<12
breaths/min), absent patellar reflexes, and oliguria (<30 mL/hr or 100 mL/4hr). The
antidote is calcium gluconate 1g IV. The infusion must be stopped immediately to
prevent respiratory arrest and cardiac arrest. Continuing (A) would be lethal. Diuretics
(C) worsen magnesium retention. Supine position (D) causes aortocaval compression.
Q7. The nurse is assessing a client at 20 weeks gestation. Which finding requires
immediate follow-up?
A. Fundal height at the umbilicus
B. Fetal heart rate of 150 bpm
C. Blood pressure 142/92 mmHg [CORRECT]
D. Weight gain of 3 pounds since last visit
Correct Answer: C
Rationale: Hypertension in pregnancy (≥140/90) at 20 weeks (before the typical
20-week threshold for gestational hypertension) suggests chronic hypertension or
early-onset preeclampsia, both requiring urgent evaluation. Fundal height at umbilicus
(A) is appropriate for 20 weeks. FHR 150 (B) is normal. Weight gain (D) requires context
but 3 lbs is not immediately concerning.
Q8. A client in the first stage of labor reports severe back pain. Assessment reveals the
fetus is in the occiput posterior (OP) position. Which nursing intervention is most
appropriate?
A. Encourage supine positioning with legs elevated.
B. Apply sacral pressure and encourage hands-and-knees or side-lying positions
[CORRECT]
C. Administer a stat dose of intravenous opioid.
