NSG 3100 Advanced Nursing Prep: Master Maternal-
Newborn Nursing Practice Questions & Detailed
Explanations
Subject / Subtopic: Maternal-Newborn Nursing – High-Risk Intrapartum and
Postpartum Complications
Question 1: A G3P2002 client at 34 weeks gestation is admitted with a blood pressure of
160/110 mmHg, 3+ proteinuria, and a report of a sudden, severe headache. Magnesium sulfate is
ordered. Which nursing assessment finding is most indicative of early magnesium toxicity in this
patient?
A) Respiratory rate of 14 breaths/minute
B) Diminished or absent patellar deep tendon reflexes
C) Urinary output of 40 mL/hour
D) Serum magnesium level of 5.5 mEq/L
Correct Answer: B) Diminished or absent patellar deep tendon reflexes
Explanation: Loss of patellar deep tendon reflexes is typically the first clinical sign of
magnesium toxicity, occurring as serum levels exceed the therapeutic range (usually 4–7
mEq/L). While respiratory depression (A) is a severe sign of toxicity, it occurs later than the loss
of reflexes. Urinary output of 40 mL/hour is within normal limits, and a serum level of 5.5 mEq/L
is within the therapeutic range.
Question 2: A nurse is caring for a client in active labor whose membranes just ruptured. The
fetal heart rate (FHR) monitor displays variable decelerations followed by a sudden bradycardia.
Upon vaginal examination, the nurse feels a soft, pulsating structure. Which action should the
nurse prioritize?
A) Reposition the client to the left lateral position and increase IV fluids.
B) Apply firm upward manual pressure against the presenting part to relieve cord compression.
C) Prepare for an immediate emergency cesarean section by calling for the surgical team.
D) Administer oxygen via non-rebreather mask at 10 L/minute.
Correct Answer: B) Apply firm upward manual pressure against the presenting part to
relieve cord compression.
, Explanation: The assessment findings describe an umbilical cord prolapse, a life-threatening
obstetric emergency. The priority is to immediately relieve pressure on the cord to restore blood
flow to the fetus. While the other actions are necessary, manual pressure is the first and most
critical step to preserve fetal oxygenation while preparing for the inevitable cesarean section.
Question 3: A client in the immediate postpartum period (2 hours post-delivery) has a boggy
fundus and excessive lochia rubra. The nurse performs fundal massage, but the fundus remains
soft and displaced to the right. What is the most likely cause of this finding?
A) Retained placental fragments
B) Uterine atony secondary to a full bladder
C) Cervical laceration
D) Disseminated Intravascular Coagulation (DIC)
Correct Answer: B) Uterine atony secondary to a full bladder
Explanation: A boggy fundus that is displaced to the right is a classic clinical indicator of a
distended bladder. The bladder pushes the uterus out of its midline position, preventing effective
uterine contraction and leading to atony. Catheterization or encouraging voiding should resolve
the displacement and allow the fundus to firm up.
Question 4: A nurse is monitoring a client receiving oxytocin (Pitocin) for induction of labor.
The nurse notes contractions lasting 100 seconds occurring every 90 seconds, with an FHR
baseline of 150 bpm and late decelerations. What is the nurse's priority intervention?
A) Increase the oxytocin infusion rate.
B) Administer a bolus of IV lactated Ringer’s solution.
C) Discontinue the oxytocin infusion immediately.
D) Perform a vaginal examination to check for cervical change.
Correct Answer: C) Discontinue the oxytocin infusion immediately.
Explanation: The client is experiencing uterine tachysystole (contractions too long/frequent),
which is compromising fetal oxygenation, as evidenced by late decelerations. Discontinuing the
oxytocin is the priority to reduce uterine activity and restore placental perfusion. Increasing the
dose would exacerbate the problem, and while IV fluids might be indicated, stopping the cause of
the tachysystole is paramount.
Newborn Nursing Practice Questions & Detailed
Explanations
Subject / Subtopic: Maternal-Newborn Nursing – High-Risk Intrapartum and
Postpartum Complications
Question 1: A G3P2002 client at 34 weeks gestation is admitted with a blood pressure of
160/110 mmHg, 3+ proteinuria, and a report of a sudden, severe headache. Magnesium sulfate is
ordered. Which nursing assessment finding is most indicative of early magnesium toxicity in this
patient?
A) Respiratory rate of 14 breaths/minute
B) Diminished or absent patellar deep tendon reflexes
C) Urinary output of 40 mL/hour
D) Serum magnesium level of 5.5 mEq/L
Correct Answer: B) Diminished or absent patellar deep tendon reflexes
Explanation: Loss of patellar deep tendon reflexes is typically the first clinical sign of
magnesium toxicity, occurring as serum levels exceed the therapeutic range (usually 4–7
mEq/L). While respiratory depression (A) is a severe sign of toxicity, it occurs later than the loss
of reflexes. Urinary output of 40 mL/hour is within normal limits, and a serum level of 5.5 mEq/L
is within the therapeutic range.
Question 2: A nurse is caring for a client in active labor whose membranes just ruptured. The
fetal heart rate (FHR) monitor displays variable decelerations followed by a sudden bradycardia.
Upon vaginal examination, the nurse feels a soft, pulsating structure. Which action should the
nurse prioritize?
A) Reposition the client to the left lateral position and increase IV fluids.
B) Apply firm upward manual pressure against the presenting part to relieve cord compression.
C) Prepare for an immediate emergency cesarean section by calling for the surgical team.
D) Administer oxygen via non-rebreather mask at 10 L/minute.
Correct Answer: B) Apply firm upward manual pressure against the presenting part to
relieve cord compression.
, Explanation: The assessment findings describe an umbilical cord prolapse, a life-threatening
obstetric emergency. The priority is to immediately relieve pressure on the cord to restore blood
flow to the fetus. While the other actions are necessary, manual pressure is the first and most
critical step to preserve fetal oxygenation while preparing for the inevitable cesarean section.
Question 3: A client in the immediate postpartum period (2 hours post-delivery) has a boggy
fundus and excessive lochia rubra. The nurse performs fundal massage, but the fundus remains
soft and displaced to the right. What is the most likely cause of this finding?
A) Retained placental fragments
B) Uterine atony secondary to a full bladder
C) Cervical laceration
D) Disseminated Intravascular Coagulation (DIC)
Correct Answer: B) Uterine atony secondary to a full bladder
Explanation: A boggy fundus that is displaced to the right is a classic clinical indicator of a
distended bladder. The bladder pushes the uterus out of its midline position, preventing effective
uterine contraction and leading to atony. Catheterization or encouraging voiding should resolve
the displacement and allow the fundus to firm up.
Question 4: A nurse is monitoring a client receiving oxytocin (Pitocin) for induction of labor.
The nurse notes contractions lasting 100 seconds occurring every 90 seconds, with an FHR
baseline of 150 bpm and late decelerations. What is the nurse's priority intervention?
A) Increase the oxytocin infusion rate.
B) Administer a bolus of IV lactated Ringer’s solution.
C) Discontinue the oxytocin infusion immediately.
D) Perform a vaginal examination to check for cervical change.
Correct Answer: C) Discontinue the oxytocin infusion immediately.
Explanation: The client is experiencing uterine tachysystole (contractions too long/frequent),
which is compromising fetal oxygenation, as evidenced by late decelerations. Discontinuing the
oxytocin is the priority to reduce uterine activity and restore placental perfusion. Increasing the
dose would exacerbate the problem, and while IV fluids might be indicated, stopping the cause of
the tachysystole is paramount.
