Maternal Exam 3 2026 Questions and Answers Graded A+
A client is receiving magnesium sulfate therapy for severe preeclampsia. What initial sign of toxicity should prompt the
nurse to intervene? - Correct answer-lack of knee jerk reflex
A primigravida who is at 40 weeks' gestation arrives at the birthing center with abdominal cramping and a bloody show. Her
membranes ruptured 30 minutes before arrival. A vaginal examination reveals 1 cm of dilation and the presenting part at -1
station. After obtaining the fetal heart rate and maternal vital signs, what should the nurse's priority intervention be? -
Correct answer-Provide the client with comfort measures used for women in labor.
Which statements regarding the involution process are correct? SATA. - Correct answer-Involution begins immediately after
expulsion of the placenta.
Involution progresses rapidly during the next few days after birth.
Involution is the return of the uterus to a non pregnant state after birth.
The nurse places fetal and uterine monitors on the abdomen of a client in labor. While observing the relationship between
the fetal heart rate and uterine contractions, the nurse identifies four late decelerations. Which condition is most commonly
associated with late decelerations? - Correct answer-Uteroplacental insufficiency
During a client's labor the fetal monitor reveals a fetal heart pattern that signifies uteroplacental insufficiency. What is the
nurse's priority intervention? - Correct answer-Helping the client turn to the side lying position
A client asks the nurse at the prenatal clinic whether she may continue to have sexual relations while pregnant. What is one
indication that the client should refrain from intercourse during pregnancy? - Correct answer-Premature rupture of
membranes
A client is scheduled for a sonogram at 36 weeks' gestation. Shortly before the test she tells the nurse that she is
experiencing severe abdominal pain. Assessment reveals heavy vaginal bleeding, a drop in blood pressure, and an increased
pulse rate. Which complication does the nurse suspect? - Correct answer-Complete abruptio placentae
The nurse is obtaining the health history of a woman who is visiting the prenatal clinic for the first time. She states that she
is 5 months pregnant. Which positive sign of pregnancy should the nurse evaluate in this client? - Correct answer-Audible
fetal heartbeat
The nurse is caring for a client who has had a spontaneous abortion. Which complication should the nurse assess this client
for? - Correct answer-Hemorrhage
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,A client at 35 weeks' gestation asks the nurse why her breathing has become more difficult. How should the nurse respond?
- Correct answer-"Your diaphragm has been displaced upward."
A pregnant client comes to the emergency department because of vaginal bleeding. The nurse asks the client to estimate
how heavy the bleeding is. What is the best gauge for the client to use? - Correct answer-Amount of blood lost in relation to
usual menstrual flow.
While observing a mother visiting her preterm son in the neonatal intensive care nursery, the nurse notes that she has not yet
begun the bonding process. Which statement by the mother supports the nurse's conclusion? - Correct answer-"It's such a
tiny baby."
A pregnant client's history reveals opioid abuse. What is the nurse's initial plan for providing pain relief measures during
labor? - Correct answer-Scheduling pain medication at regular intervals.
A client in the birthing suite has spontaneous rupture of the membranes, after which a prolapsed cord is identified. The
nurse calls for help and with a sterile gloved hand moves the fetal head off the cord. What should the nurse anticipate? -
Correct answer-C section
What statement by a breast-feeding mother indicates that the nurse's teaching regarding stimulating the let-down reflex has
been successful? - Correct answer-"I will apply warm packs and massage my breasts before each feeding."
The nurse applies fetal and uterine monitors to the abdomen of a client in active labor. When the client has contractions, the
nurse notes a 15 beats/min deceleration of the fetal heart rate below the baseline lasting 15 seconds. What is the next
nursing action? - Correct answer-Change the maternal position
A client is scheduled for a nonstress test in the 37th week of gestation. The nurse explains the procedure. Which statement
demonstrates that the client understands the teaching? - Correct answer-"If the heart reacts well, my baby should do ok
when I give birth."
What is the priority nursing intervention during the admission of a primigravida in labor? - Correct answer-Monitoring the
fetal heart rate
What type of lochia should the visiting nurse expect to observe on a client's pad on the fourth day after a vaginal delivery? -
Correct answer-Moderate serosa
While caring for a client who gave birth 1 day ago, the nurse determines that the client's uterine fundus is firm at one
fingerbreadth below the umbilicus, blood pressure is 110/70 mm Hg, pulse is 72 beats per minute, and respirations are 16
breaths per minute. The client's perineal pad is saturated with lochia rubra. What is the priority nursing action? - Correct
answer-Asking the client when she last changed the perineal pad
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, A client who is in preterm labor at 34 weeks' gestation is receiving intravenous tocolytic therapy. The frequency of her
contractions increases to every 10 minutes, and her cervix dilates to 4 cm. The infusion is discontinued. Toward what
outcome should the priority nursing care be directed at this time? - Correct answer-Promotion of maternal and fetal well
being during labor
While a multiparous client is in active labor, her membranes rupture spontaneously. The nurse notes a loop of umbilical cord
protruding from her vagina. What is the priority nursing action at this time? - Correct answer-Holding the presenting part
away from the cord
How should a nurse cirect care for a client in the transition phase of the first stage of labor? - Correct answer-Helping the
client maintain control
A 16-year-old primigravida who appears to be at or close to term arrives at the emergency department stating that she is in
labor and complaining of pain continuing between contractions. The nurse palpates the abdomen, which is firm and shows
no sign of relaxation. What problem does the nurse conclude that the client is experiencing? - Correct answer-Abruptio
placentae
A 36-year-old woman, G1 P0, is admitted to the labor and delivery unit for oxytocin induction. She is at 40 weeks'
gestation. Which condition is a contraindication to the use of oxytocin induction? - Correct answer-Active genital herpes
infection
A 20-year-old woman is admitted to the labor and delivery unit after reporting that she is experiencing severe contractions.
She is 38 weeks +2 days' gestation. External fetal monitoring has been initiated. During the assessment the nurse notes that
the woman is sweating profusely, has dilated pupils and irregular respirations, is hypertensive, and continues to complain of
very severe pain with contractions. The external fetal monitor shows fetal tachycardia with excessive fetal activity. What
should the nurse suspect? - Correct answer-Cocaine abuse
The nurse is caring for a client in active labor at a birthing center. She is 100% effaced, dilated 3 cm, and at +1 station. In
which stage of labor is this client? - Correct answer-First
A client's membranes rupture while her labor is being augmented with an oxytocin infusion. The nurse observes variable
decelerations in the fetal heart rate on the fetal monitor strip. Which action should the nurse initiate next? - Correct answer-
Changing the client's position
The cervix of a client in labor is fully dilated and effaced. The head of the fetus is at +2 station. What should the nurse
encourage the client to do during contractions? - Correct answer-Push with her glottis open
A nurse suspects cephalopelvic disproportion in a client who is having a difficult labor. For which test should the nurse
prepare the client? - Correct answer-Ultrasound
© COPYRIGHT 2026,ALL RIGHTS RESERVED 3
A client is receiving magnesium sulfate therapy for severe preeclampsia. What initial sign of toxicity should prompt the
nurse to intervene? - Correct answer-lack of knee jerk reflex
A primigravida who is at 40 weeks' gestation arrives at the birthing center with abdominal cramping and a bloody show. Her
membranes ruptured 30 minutes before arrival. A vaginal examination reveals 1 cm of dilation and the presenting part at -1
station. After obtaining the fetal heart rate and maternal vital signs, what should the nurse's priority intervention be? -
Correct answer-Provide the client with comfort measures used for women in labor.
Which statements regarding the involution process are correct? SATA. - Correct answer-Involution begins immediately after
expulsion of the placenta.
Involution progresses rapidly during the next few days after birth.
Involution is the return of the uterus to a non pregnant state after birth.
The nurse places fetal and uterine monitors on the abdomen of a client in labor. While observing the relationship between
the fetal heart rate and uterine contractions, the nurse identifies four late decelerations. Which condition is most commonly
associated with late decelerations? - Correct answer-Uteroplacental insufficiency
During a client's labor the fetal monitor reveals a fetal heart pattern that signifies uteroplacental insufficiency. What is the
nurse's priority intervention? - Correct answer-Helping the client turn to the side lying position
A client asks the nurse at the prenatal clinic whether she may continue to have sexual relations while pregnant. What is one
indication that the client should refrain from intercourse during pregnancy? - Correct answer-Premature rupture of
membranes
A client is scheduled for a sonogram at 36 weeks' gestation. Shortly before the test she tells the nurse that she is
experiencing severe abdominal pain. Assessment reveals heavy vaginal bleeding, a drop in blood pressure, and an increased
pulse rate. Which complication does the nurse suspect? - Correct answer-Complete abruptio placentae
The nurse is obtaining the health history of a woman who is visiting the prenatal clinic for the first time. She states that she
is 5 months pregnant. Which positive sign of pregnancy should the nurse evaluate in this client? - Correct answer-Audible
fetal heartbeat
The nurse is caring for a client who has had a spontaneous abortion. Which complication should the nurse assess this client
for? - Correct answer-Hemorrhage
© COPYRIGHT 2026,ALL RIGHTS RESERVED 1
,A client at 35 weeks' gestation asks the nurse why her breathing has become more difficult. How should the nurse respond?
- Correct answer-"Your diaphragm has been displaced upward."
A pregnant client comes to the emergency department because of vaginal bleeding. The nurse asks the client to estimate
how heavy the bleeding is. What is the best gauge for the client to use? - Correct answer-Amount of blood lost in relation to
usual menstrual flow.
While observing a mother visiting her preterm son in the neonatal intensive care nursery, the nurse notes that she has not yet
begun the bonding process. Which statement by the mother supports the nurse's conclusion? - Correct answer-"It's such a
tiny baby."
A pregnant client's history reveals opioid abuse. What is the nurse's initial plan for providing pain relief measures during
labor? - Correct answer-Scheduling pain medication at regular intervals.
A client in the birthing suite has spontaneous rupture of the membranes, after which a prolapsed cord is identified. The
nurse calls for help and with a sterile gloved hand moves the fetal head off the cord. What should the nurse anticipate? -
Correct answer-C section
What statement by a breast-feeding mother indicates that the nurse's teaching regarding stimulating the let-down reflex has
been successful? - Correct answer-"I will apply warm packs and massage my breasts before each feeding."
The nurse applies fetal and uterine monitors to the abdomen of a client in active labor. When the client has contractions, the
nurse notes a 15 beats/min deceleration of the fetal heart rate below the baseline lasting 15 seconds. What is the next
nursing action? - Correct answer-Change the maternal position
A client is scheduled for a nonstress test in the 37th week of gestation. The nurse explains the procedure. Which statement
demonstrates that the client understands the teaching? - Correct answer-"If the heart reacts well, my baby should do ok
when I give birth."
What is the priority nursing intervention during the admission of a primigravida in labor? - Correct answer-Monitoring the
fetal heart rate
What type of lochia should the visiting nurse expect to observe on a client's pad on the fourth day after a vaginal delivery? -
Correct answer-Moderate serosa
While caring for a client who gave birth 1 day ago, the nurse determines that the client's uterine fundus is firm at one
fingerbreadth below the umbilicus, blood pressure is 110/70 mm Hg, pulse is 72 beats per minute, and respirations are 16
breaths per minute. The client's perineal pad is saturated with lochia rubra. What is the priority nursing action? - Correct
answer-Asking the client when she last changed the perineal pad
© COPYRIGHT 2026,ALL RIGHTS RESERVED 2
, A client who is in preterm labor at 34 weeks' gestation is receiving intravenous tocolytic therapy. The frequency of her
contractions increases to every 10 minutes, and her cervix dilates to 4 cm. The infusion is discontinued. Toward what
outcome should the priority nursing care be directed at this time? - Correct answer-Promotion of maternal and fetal well
being during labor
While a multiparous client is in active labor, her membranes rupture spontaneously. The nurse notes a loop of umbilical cord
protruding from her vagina. What is the priority nursing action at this time? - Correct answer-Holding the presenting part
away from the cord
How should a nurse cirect care for a client in the transition phase of the first stage of labor? - Correct answer-Helping the
client maintain control
A 16-year-old primigravida who appears to be at or close to term arrives at the emergency department stating that she is in
labor and complaining of pain continuing between contractions. The nurse palpates the abdomen, which is firm and shows
no sign of relaxation. What problem does the nurse conclude that the client is experiencing? - Correct answer-Abruptio
placentae
A 36-year-old woman, G1 P0, is admitted to the labor and delivery unit for oxytocin induction. She is at 40 weeks'
gestation. Which condition is a contraindication to the use of oxytocin induction? - Correct answer-Active genital herpes
infection
A 20-year-old woman is admitted to the labor and delivery unit after reporting that she is experiencing severe contractions.
She is 38 weeks +2 days' gestation. External fetal monitoring has been initiated. During the assessment the nurse notes that
the woman is sweating profusely, has dilated pupils and irregular respirations, is hypertensive, and continues to complain of
very severe pain with contractions. The external fetal monitor shows fetal tachycardia with excessive fetal activity. What
should the nurse suspect? - Correct answer-Cocaine abuse
The nurse is caring for a client in active labor at a birthing center. She is 100% effaced, dilated 3 cm, and at +1 station. In
which stage of labor is this client? - Correct answer-First
A client's membranes rupture while her labor is being augmented with an oxytocin infusion. The nurse observes variable
decelerations in the fetal heart rate on the fetal monitor strip. Which action should the nurse initiate next? - Correct answer-
Changing the client's position
The cervix of a client in labor is fully dilated and effaced. The head of the fetus is at +2 station. What should the nurse
encourage the client to do during contractions? - Correct answer-Push with her glottis open
A nurse suspects cephalopelvic disproportion in a client who is having a difficult labor. For which test should the nurse
prepare the client? - Correct answer-Ultrasound
© COPYRIGHT 2026,ALL RIGHTS RESERVED 3
