NSG 3500 Final Exam V2 | NSG 3500
Maternal Health Review | Actual Q&A with
Rationale (NSG3500 Final Exam) | Galen
College of Nursing
1. A nurse is assessing a pregnant client at 30 weeks of gestation. Which of the following
findings should the nurse report to the provider as a possible indicator of preeclampsia?
A. 1+ pedal edema at the end of the day
B. Occasional Braxton Hicks contractions
C. Increased urinary frequency
D. Swelling of the face and fingers
Answer: D
Rationale: Swelling of the face and fingers, also known as facial or periorbital edema, is a
classic warning sign of preeclampsia that requires further investigation. While dependent
pedal edema is common in late pregnancy, generalized edema above the waist is more
concerning. The nurse must assess the blood pressure and check for proteinuria to confirm
the diagnosis.
2. A client is in the active phase of the first stage of labor. The nurse notes the fetal heart rate
(FHR) shows late decelerations. Which of the following actions is the priority?
A. Increase the oxytocin infusion rate
,B. Perform a vaginal examination
C. Prepare for an immediate forceps delivery
D. Assist the client into a side-lying position
Answer: D
Rationale: Assisting the client into a side-lying position is the priority intervention to
improve uteroplacental blood flow. Late decelerations are indicative of placental
insufficiency and require immediate intrauterine resuscitation. Following repositioning,
the nurse should administer oxygen and increase IV fluids while discontinuing oxytocin if
applicable.
3. A nurse is caring for a client who is 4 hours postpartum. The nurse notes the fundus is firm,
midline, and two fingerbreadths below the umbilicus, but the client is experiencing heavy
vaginal bleeding. Which of the following is the most likely cause?
A. Uterine atony
B. Lacerations of the birth canal
C. Retained placental fragments
D. Full urinary bladder
Answer: B
Rationale: Vaginal bleeding in the presence of a firm, contracted uterus is a classic sign of
lacerations of the cervix or vagina. Uterine atony would present with a boggy uterus rather
, than a firm one. The nurse should notify the provider to inspect the birth canal for trauma
that requires repair.
4. A nurse is teaching a client about the use of Magnesium Sulfate for preeclampsia. Which of
the following statements by the client indicates an understanding of the medication?
A. This medicine is meant to lower my high blood pressure
B. This medicine will stop my contractions from occurring
C. This medicine will help my baby’s lungs mature faster
D. This medicine is used to prevent seizures from happening
Answer: D
Rationale: Magnesium Sulfate is primarily administered as a central nervous system
depressant to prevent eclamptic seizures in clients with preeclampsia. It is not an
antihypertensive, although it may cause a slight, transient drop in blood pressure. The
nurse should explain that monitoring for toxicity involves checking deep tendon reflexes
and respiratory rate.
5. A newborn is 5 minutes old and has a heart rate of 110/min, a weak cry, some flexion of
the extremities, grimacing when stimulated, and a pink body with blue hands and feet. What
is the Apgar score?
A. 5
B. 8
C. 7
Maternal Health Review | Actual Q&A with
Rationale (NSG3500 Final Exam) | Galen
College of Nursing
1. A nurse is assessing a pregnant client at 30 weeks of gestation. Which of the following
findings should the nurse report to the provider as a possible indicator of preeclampsia?
A. 1+ pedal edema at the end of the day
B. Occasional Braxton Hicks contractions
C. Increased urinary frequency
D. Swelling of the face and fingers
Answer: D
Rationale: Swelling of the face and fingers, also known as facial or periorbital edema, is a
classic warning sign of preeclampsia that requires further investigation. While dependent
pedal edema is common in late pregnancy, generalized edema above the waist is more
concerning. The nurse must assess the blood pressure and check for proteinuria to confirm
the diagnosis.
2. A client is in the active phase of the first stage of labor. The nurse notes the fetal heart rate
(FHR) shows late decelerations. Which of the following actions is the priority?
A. Increase the oxytocin infusion rate
,B. Perform a vaginal examination
C. Prepare for an immediate forceps delivery
D. Assist the client into a side-lying position
Answer: D
Rationale: Assisting the client into a side-lying position is the priority intervention to
improve uteroplacental blood flow. Late decelerations are indicative of placental
insufficiency and require immediate intrauterine resuscitation. Following repositioning,
the nurse should administer oxygen and increase IV fluids while discontinuing oxytocin if
applicable.
3. A nurse is caring for a client who is 4 hours postpartum. The nurse notes the fundus is firm,
midline, and two fingerbreadths below the umbilicus, but the client is experiencing heavy
vaginal bleeding. Which of the following is the most likely cause?
A. Uterine atony
B. Lacerations of the birth canal
C. Retained placental fragments
D. Full urinary bladder
Answer: B
Rationale: Vaginal bleeding in the presence of a firm, contracted uterus is a classic sign of
lacerations of the cervix or vagina. Uterine atony would present with a boggy uterus rather
, than a firm one. The nurse should notify the provider to inspect the birth canal for trauma
that requires repair.
4. A nurse is teaching a client about the use of Magnesium Sulfate for preeclampsia. Which of
the following statements by the client indicates an understanding of the medication?
A. This medicine is meant to lower my high blood pressure
B. This medicine will stop my contractions from occurring
C. This medicine will help my baby’s lungs mature faster
D. This medicine is used to prevent seizures from happening
Answer: D
Rationale: Magnesium Sulfate is primarily administered as a central nervous system
depressant to prevent eclamptic seizures in clients with preeclampsia. It is not an
antihypertensive, although it may cause a slight, transient drop in blood pressure. The
nurse should explain that monitoring for toxicity involves checking deep tendon reflexes
and respiratory rate.
5. A newborn is 5 minutes old and has a heart rate of 110/min, a weak cry, some flexion of
the extremities, grimacing when stimulated, and a pink body with blue hands and feet. What
is the Apgar score?
A. 5
B. 8
C. 7
