UR 202/ NUR202 Exam 3 –
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Maternal-Newborn Nursing Review
ACTUAL EXAM 2026/2027 |
Maternal-Newborn Nursing Review |
Verified Q&A | Pass Guaranteed - A+
Graded
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PART A – MULTIPLE CHOICE (Q1-60)
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* *Q1 (Neurological – acute ischemic stroke):**
A 68-year-old male is brought to the ED with sudden onset left-sided weakness and slurred
speech. His wife states symptoms began 2.5 hours ago. BP is 178/96 mmHg. The nurse knows
the priority action before considering tPA is:
A. Administer labetalol to lower BP to <140/90 mmHg immediately
B. Obtain a non-contrast CT scan to rule out hemorrhage
C. Insert a nasogastric tube for airway protection
D. Start a heparin drip at 18 units/kg/hr
* *[CORRECT]** B
*Rationale: AHA/ASA 2026 guidelines for acute ischemic stroke require a non-contrast CT scan
to exclude intracranial hemorrhage before administering tPA, as tPA is contraindicated in
hemorrhagic stroke. Option A is incorrect because aggressive BP lowering before imaging may
worsen ischemia; the goal is <185/110 mmHg for tPA eligibility, not <140/90. Option C is
incorrect because NGT insertion is not indicated unless the patient has impaired gag reflex or
vomiting. Option D is incorrect because heparin is contraindicated within 24 hours of tPA and is
not a first-line intervention for acute ischemic stroke. Clinical pearl: Time is brain — every
minute of delayed imaging reduces the potential benefit of reperfusion therapy.*
**Q2 (Neurological – tPA eligibility):**
, hich finding would make a patient INELIGIBLE for tPA administration in acute ischemic
W
stroke?
A. NIHSS score of 14
B. Blood glucose of 68 mg/dL
C. Recent gastrointestinal bleeding 10 days ago
D. Age 82 years
* *[CORRECT]** C
*Rationale: AHA/ASA 2026 guidelines list active internal bleeding within 21 days as an absolute
contraindication to tPA due to risk of fatal hemorrhage. Option A is incorrect because NIHSS
scores between 4-25 are generally appropriate for tPA. Option B is incorrect because
hypoglycemia should be corrected but does not exclude tPA if stroke symptoms persist after
glucose normalization. Option D is incorrect because advanced age alone is not a
contraindication; tPA benefit extends to patients over 80. Clinical pearl: Always verify the last
known well time — tPA window is 4.5 hours from symptom onset or last known normal.*
* *Q3 (Neurological – NIHSS):**
The nurse is assessing a patient 2 hours post-tPA using the NIH Stroke Scale. Which finding
would indicate the MOST severe neurological deficit?
A. Mild facial droop (score 1)
B. Complete paralysis of left leg (score 4)
C. Moderate aphasia (score 2)
D. Visual fields intact (score 0)
* *[CORRECT]** B
*Rationale: The NIHSS scores motor deficits from 0 (no drift) to 4 (no movement against
gravity), with complete paralysis representing the most severe impairment and greatest
functional disability. Option A is incorrect because facial droop scores only 0-3 and indicates
less severe deficit. Option C is incorrect because aphasia, while serious, scores 0-3 and does
not indicate the same immediate physical disability as complete paralysis. Option D is incorrect
because intact visual fields represent no deficit (score 0). Clinical pearl: Higher NIHSS scores
(>15) correlate with larger infarct volume and worse outcomes; scores >22 may indicate need
for mechanical thrombectomy.*
* *Q4 (Neurological – hemorrhagic stroke):**
A patient with a known history of uncontrolled hypertension presents with a sudden thunderclap
headache, vomiting, and decreased level of consciousness. CT scan reveals intracerebral
hemorrhage. The nurse's priority intervention is:
A. Administer tPA immediately to dissolve the clot
B. Maintain systolic BP between 140-160 mmHg
C. Elevate the head of the bed to 90 degrees
D. Insert an arterial line and maintain MAP >110 mmHg
**[CORRECT]** B
,* Rationale: AHA/ASA 2026 guidelines for spontaneous intracerebral hemorrhage recommend
maintaining systolic BP between 140-160 mmHg to prevent hematoma expansion while
preserving cerebral perfusion. Option A is incorrect because tPA is absolutely contraindicated in
hemorrhagic stroke and would worsen bleeding. Option C is incorrect because while head
elevation to 30 degrees is standard, 90 degrees may compromise cerebral perfusion. Option D
is incorrect because maintaining MAP >110 mmHg would increase bleeding risk; the goal is
controlled, not elevated, blood pressure. Clinical pearl: Hemorrhagic stroke carries higher
30-day mortality than ischemic stroke; rapid BP control and neurosurgical consultation are
critical.*
* *Q5 (Neurological – increased ICP):**
A patient with a traumatic brain injury develops Cushing's triad. Which set of vital signs is MOST
consistent with this finding?
A. BP 90/50, HR 120, RR 28
B. BP 180/50, HR 48, RR 8 with irregular pattern
C. BP 110/70, HR 88, RR 16
D. BP 130/80, HR 110, RR 24
* *[CORRECT]** B
*Rationale: Cushing's triad consists of hypertension (systolic elevation with widened pulse
pressure), bradycardia, and irregular respirations — a late sign of critically increased ICP as the
brainstem becomes compressed. Option A is incorrect because hypotension and tachycardia
indicate shock, not increased ICP. Option C is incorrect because these are normal vital signs.
Option D is incorrect because tachycardia and tachypnea are not components of Cushing's
triad. Clinical pearl: Cushing's triad is a pre-terminal sign; immediate intervention with mannitol,
hyperventilation, and neurosurgical consultation is required.*
* *Q6 (Neurological – CPP calculation):**
A patient with increased ICP has a MAP of 85 mmHg and ICP of 22 mmHg. What is the cerebral
perfusion pressure (CPP)?
A. 107 mmHg
B. 63 mmHg
C. 107 mmHg
D. 43 mmHg
* *[CORRECT]** B
*Rationale: CPP = MAP – ICP; therefore 85 – 22 = 63 mmHg. The Brain Trauma Foundation
recommends maintaining CPP between 60-70 mmHg in adults with severe TBI. Option A is
incorrect because it adds MAP and ICP rather than subtracting. Option C is a duplicate of A.
Option D is incorrect because it subtracts MAP from ICP. Clinical pearl: CPP <60 mmHg
indicates inadequate cerebral perfusion and risk of secondary brain injury; interventions to lower
ICP (mannitol, hyperventilation, drainage) or increase MAP (fluids, vasopressors) may be
needed.*
, * *Q7 (Neurological – mannitol):**
The nurse is administering mannitol 1 g/kg IV for increased ICP. Which assessment is MOST
important before administration?
A. Check serum sodium level
B. Assess serum osmolality
C. Verify platelet count
D. Check blood glucose
* *[CORRECT]** B
*Rationale: Mannitol is an osmotic diuretic that can cause hyperosmolar state and renal
dysfunction; serum osmolality should be checked and should not exceed 320 mOsm/kg before
repeat dosing. Option A is incorrect because while sodium may rise with mannitol, osmolality is
the direct safety parameter. Option C is incorrect because mannitol does not affect platelet
function. Option D is incorrect because mannitol is not contraindicated by glucose levels.
Clinical pearl: Mannitol crystallizes at low temperatures — inspect the IV bag for crystals and
use an in-line filter; administer over 15-30 minutes for ICP crisis.*
* *Q8 (Neurological – seizures):**
A patient is having a generalized tonic-clonic seizure that has lasted 4 minutes. The nurse's
FIRST action is:
A. Insert an oropharyngeal airway to maintain the airway
B. Administer lorazepam 4 mg IV push
C. Turn the patient to the side and protect from injury
D. Start a phenytoin drip at 20 mg/kg
* *[CORRECT]** C
*Rationale: The first priority in any seizure is safety — positioning the patient laterally prevents
aspiration, and clearing the environment prevents injury; never insert anything into the mouth
during active seizure. Option A is incorrect because inserting an airway during active seizure
risks dental trauma and is not feasible. Option B is incorrect because while lorazepam is
first-line for status epilepticus, safety measures precede medication. Option D is incorrect
because phenytoin is second-line and requires cardiac monitoring during administration. Clinical
pearl: Status epilepticus is defined as >5 minutes of continuous seizure or recurrent seizures
without recovery; benzodiazepines are first-line, followed by fosphenytoin or levetiracetam.*
* *Q9 (Neurological – status epilepticus):**
A patient in status epilepticus has received lorazepam 4 mg IV without cessation of seizure
activity. The NEXT appropriate medication is:
A. Repeat lorazepam 4 mg IV in 5 minutes
B. Fosphenytoin 20 mg PE/kg IV
C. Phenobarbital 20 mg/kg IV
D. Levetiracetam 1000 mg IV
**[CORRECT]** B
N
Maternal-Newborn Nursing Review
ACTUAL EXAM 2026/2027 |
Maternal-Newborn Nursing Review |
Verified Q&A | Pass Guaranteed - A+
Graded
=======================================================================
=
========
PART A – MULTIPLE CHOICE (Q1-60)
========================================================================
========
* *Q1 (Neurological – acute ischemic stroke):**
A 68-year-old male is brought to the ED with sudden onset left-sided weakness and slurred
speech. His wife states symptoms began 2.5 hours ago. BP is 178/96 mmHg. The nurse knows
the priority action before considering tPA is:
A. Administer labetalol to lower BP to <140/90 mmHg immediately
B. Obtain a non-contrast CT scan to rule out hemorrhage
C. Insert a nasogastric tube for airway protection
D. Start a heparin drip at 18 units/kg/hr
* *[CORRECT]** B
*Rationale: AHA/ASA 2026 guidelines for acute ischemic stroke require a non-contrast CT scan
to exclude intracranial hemorrhage before administering tPA, as tPA is contraindicated in
hemorrhagic stroke. Option A is incorrect because aggressive BP lowering before imaging may
worsen ischemia; the goal is <185/110 mmHg for tPA eligibility, not <140/90. Option C is
incorrect because NGT insertion is not indicated unless the patient has impaired gag reflex or
vomiting. Option D is incorrect because heparin is contraindicated within 24 hours of tPA and is
not a first-line intervention for acute ischemic stroke. Clinical pearl: Time is brain — every
minute of delayed imaging reduces the potential benefit of reperfusion therapy.*
**Q2 (Neurological – tPA eligibility):**
, hich finding would make a patient INELIGIBLE for tPA administration in acute ischemic
W
stroke?
A. NIHSS score of 14
B. Blood glucose of 68 mg/dL
C. Recent gastrointestinal bleeding 10 days ago
D. Age 82 years
* *[CORRECT]** C
*Rationale: AHA/ASA 2026 guidelines list active internal bleeding within 21 days as an absolute
contraindication to tPA due to risk of fatal hemorrhage. Option A is incorrect because NIHSS
scores between 4-25 are generally appropriate for tPA. Option B is incorrect because
hypoglycemia should be corrected but does not exclude tPA if stroke symptoms persist after
glucose normalization. Option D is incorrect because advanced age alone is not a
contraindication; tPA benefit extends to patients over 80. Clinical pearl: Always verify the last
known well time — tPA window is 4.5 hours from symptom onset or last known normal.*
* *Q3 (Neurological – NIHSS):**
The nurse is assessing a patient 2 hours post-tPA using the NIH Stroke Scale. Which finding
would indicate the MOST severe neurological deficit?
A. Mild facial droop (score 1)
B. Complete paralysis of left leg (score 4)
C. Moderate aphasia (score 2)
D. Visual fields intact (score 0)
* *[CORRECT]** B
*Rationale: The NIHSS scores motor deficits from 0 (no drift) to 4 (no movement against
gravity), with complete paralysis representing the most severe impairment and greatest
functional disability. Option A is incorrect because facial droop scores only 0-3 and indicates
less severe deficit. Option C is incorrect because aphasia, while serious, scores 0-3 and does
not indicate the same immediate physical disability as complete paralysis. Option D is incorrect
because intact visual fields represent no deficit (score 0). Clinical pearl: Higher NIHSS scores
(>15) correlate with larger infarct volume and worse outcomes; scores >22 may indicate need
for mechanical thrombectomy.*
* *Q4 (Neurological – hemorrhagic stroke):**
A patient with a known history of uncontrolled hypertension presents with a sudden thunderclap
headache, vomiting, and decreased level of consciousness. CT scan reveals intracerebral
hemorrhage. The nurse's priority intervention is:
A. Administer tPA immediately to dissolve the clot
B. Maintain systolic BP between 140-160 mmHg
C. Elevate the head of the bed to 90 degrees
D. Insert an arterial line and maintain MAP >110 mmHg
**[CORRECT]** B
,* Rationale: AHA/ASA 2026 guidelines for spontaneous intracerebral hemorrhage recommend
maintaining systolic BP between 140-160 mmHg to prevent hematoma expansion while
preserving cerebral perfusion. Option A is incorrect because tPA is absolutely contraindicated in
hemorrhagic stroke and would worsen bleeding. Option C is incorrect because while head
elevation to 30 degrees is standard, 90 degrees may compromise cerebral perfusion. Option D
is incorrect because maintaining MAP >110 mmHg would increase bleeding risk; the goal is
controlled, not elevated, blood pressure. Clinical pearl: Hemorrhagic stroke carries higher
30-day mortality than ischemic stroke; rapid BP control and neurosurgical consultation are
critical.*
* *Q5 (Neurological – increased ICP):**
A patient with a traumatic brain injury develops Cushing's triad. Which set of vital signs is MOST
consistent with this finding?
A. BP 90/50, HR 120, RR 28
B. BP 180/50, HR 48, RR 8 with irregular pattern
C. BP 110/70, HR 88, RR 16
D. BP 130/80, HR 110, RR 24
* *[CORRECT]** B
*Rationale: Cushing's triad consists of hypertension (systolic elevation with widened pulse
pressure), bradycardia, and irregular respirations — a late sign of critically increased ICP as the
brainstem becomes compressed. Option A is incorrect because hypotension and tachycardia
indicate shock, not increased ICP. Option C is incorrect because these are normal vital signs.
Option D is incorrect because tachycardia and tachypnea are not components of Cushing's
triad. Clinical pearl: Cushing's triad is a pre-terminal sign; immediate intervention with mannitol,
hyperventilation, and neurosurgical consultation is required.*
* *Q6 (Neurological – CPP calculation):**
A patient with increased ICP has a MAP of 85 mmHg and ICP of 22 mmHg. What is the cerebral
perfusion pressure (CPP)?
A. 107 mmHg
B. 63 mmHg
C. 107 mmHg
D. 43 mmHg
* *[CORRECT]** B
*Rationale: CPP = MAP – ICP; therefore 85 – 22 = 63 mmHg. The Brain Trauma Foundation
recommends maintaining CPP between 60-70 mmHg in adults with severe TBI. Option A is
incorrect because it adds MAP and ICP rather than subtracting. Option C is a duplicate of A.
Option D is incorrect because it subtracts MAP from ICP. Clinical pearl: CPP <60 mmHg
indicates inadequate cerebral perfusion and risk of secondary brain injury; interventions to lower
ICP (mannitol, hyperventilation, drainage) or increase MAP (fluids, vasopressors) may be
needed.*
, * *Q7 (Neurological – mannitol):**
The nurse is administering mannitol 1 g/kg IV for increased ICP. Which assessment is MOST
important before administration?
A. Check serum sodium level
B. Assess serum osmolality
C. Verify platelet count
D. Check blood glucose
* *[CORRECT]** B
*Rationale: Mannitol is an osmotic diuretic that can cause hyperosmolar state and renal
dysfunction; serum osmolality should be checked and should not exceed 320 mOsm/kg before
repeat dosing. Option A is incorrect because while sodium may rise with mannitol, osmolality is
the direct safety parameter. Option C is incorrect because mannitol does not affect platelet
function. Option D is incorrect because mannitol is not contraindicated by glucose levels.
Clinical pearl: Mannitol crystallizes at low temperatures — inspect the IV bag for crystals and
use an in-line filter; administer over 15-30 minutes for ICP crisis.*
* *Q8 (Neurological – seizures):**
A patient is having a generalized tonic-clonic seizure that has lasted 4 minutes. The nurse's
FIRST action is:
A. Insert an oropharyngeal airway to maintain the airway
B. Administer lorazepam 4 mg IV push
C. Turn the patient to the side and protect from injury
D. Start a phenytoin drip at 20 mg/kg
* *[CORRECT]** C
*Rationale: The first priority in any seizure is safety — positioning the patient laterally prevents
aspiration, and clearing the environment prevents injury; never insert anything into the mouth
during active seizure. Option A is incorrect because inserting an airway during active seizure
risks dental trauma and is not feasible. Option B is incorrect because while lorazepam is
first-line for status epilepticus, safety measures precede medication. Option D is incorrect
because phenytoin is second-line and requires cardiac monitoring during administration. Clinical
pearl: Status epilepticus is defined as >5 minutes of continuous seizure or recurrent seizures
without recovery; benzodiazepines are first-line, followed by fosphenytoin or levetiracetam.*
* *Q9 (Neurological – status epilepticus):**
A patient in status epilepticus has received lorazepam 4 mg IV without cessation of seizure
activity. The NEXT appropriate medication is:
A. Repeat lorazepam 4 mg IV in 5 minutes
B. Fosphenytoin 20 mg PE/kg IV
C. Phenobarbital 20 mg/kg IV
D. Levetiracetam 1000 mg IV
**[CORRECT]** B
