NSG 3500 Final Exam V3 | NSG 3500
Maternal Health Review | Actual Q&A with
Rationale (NSG3500 Final Exam) | Galen
College of Nursing
1. A nurse is assessing a client who is at 30 weeks of gestation and has preeclampsia. Which
of the following findings should the nurse report to the provider immediately?
A. 1+ dependent edema in the lower extremities
B. Urine output of 20 mL/hr over the last 2 hours
C. Blood pressure of 148/94 mmHg
D. Weight gain of 1 lb in the past week
Answer: B
Rationale: A urine output of less than 30 mL/hr is a sign of decreased renal perfusion and
may indicate worsening preeclampsia or progressing renal failure. This finding requires
immediate notification of the provider to prevent further complications like eclampsia.
Edema and mild hypertension are expected findings in preeclampsia, while 1 lb weight gain
per week is within normal limits for late pregnancy.
2. A client is receiving Magnesium Sulfate for the management of preeclampsia. Which
assessment finding indicates the nurse should stop the infusion?
A. Respiratory rate of 14 breaths/minute
,B. Deep tendon reflexes of 2+
C. Urinary output of 40 mL/hr
D. Absent patellar reflex
Answer: D
Rationale: Loss of deep tendon reflexes, such as the patellar reflex, is an early sign of
magnesium toxicity. The nurse must stop the infusion immediately to prevent respiratory
or cardiac arrest. Other signs of toxicity include respiratory depression and extreme
lethargy, while a rate of 14 breaths/minute and 2+ reflexes are within therapeutic
expectations.
3. A nurse is caring for a client in the first stage of labor and notes late decelerations on the
fetal heart rate monitor. Which of the following actions should the nurse take first?
A. Increase the rate of the oxytocin infusion
B. Prepare for an immediate vaginal exam
C. Assist the client into a side-lying position
D. Administer oxygen via a simple face mask at 2 L/min
Answer: C
Rationale: Late decelerations are caused by uteroplacental insufficiency and require
immediate nursing intervention. The first action is to improve placental blood flow by
positioning the client on her side to displace the uterus from the vena cava. Subsequent
, steps include discontinuing oxytocin, increasing IV fluids, and administering oxygen via a
non-rebreather mask at 8-10 L/min.
4. A postpartum nurse is assessing a client 2 hours after a vaginal delivery. The nurse finds the
fundus is boggy and displaced to the right. What is the priority nursing action?
A. Perform a fundal massage
B. Administer methylergonovine intramuscularly
C. Assist the client to the bathroom to void
D. Increase the IV oxytocin infusion rate
Answer: C
Rationale: A displaced fundus, especially to the right, is a classic sign of a full bladder
pushing the uterus out of position. A full bladder prevents the uterus from contracting
effectively, which significantly increases the risk of postpartum hemorrhage. Assisting the
client to empty her bladder allows the uterus to return to the midline and contract.
5. A nurse is reviewing the laboratory results for a client who is at 28 weeks of gestation.
Which of the following results should the nurse report to the provider?
A. Hemoglobin 11.5 g/dL
B. 1-hour glucose tolerance test 155 mg/dL
C. White blood cell count 12,000/mm3
D. Platelet count 160,000/mm3
Maternal Health Review | Actual Q&A with
Rationale (NSG3500 Final Exam) | Galen
College of Nursing
1. A nurse is assessing a client who is at 30 weeks of gestation and has preeclampsia. Which
of the following findings should the nurse report to the provider immediately?
A. 1+ dependent edema in the lower extremities
B. Urine output of 20 mL/hr over the last 2 hours
C. Blood pressure of 148/94 mmHg
D. Weight gain of 1 lb in the past week
Answer: B
Rationale: A urine output of less than 30 mL/hr is a sign of decreased renal perfusion and
may indicate worsening preeclampsia or progressing renal failure. This finding requires
immediate notification of the provider to prevent further complications like eclampsia.
Edema and mild hypertension are expected findings in preeclampsia, while 1 lb weight gain
per week is within normal limits for late pregnancy.
2. A client is receiving Magnesium Sulfate for the management of preeclampsia. Which
assessment finding indicates the nurse should stop the infusion?
A. Respiratory rate of 14 breaths/minute
,B. Deep tendon reflexes of 2+
C. Urinary output of 40 mL/hr
D. Absent patellar reflex
Answer: D
Rationale: Loss of deep tendon reflexes, such as the patellar reflex, is an early sign of
magnesium toxicity. The nurse must stop the infusion immediately to prevent respiratory
or cardiac arrest. Other signs of toxicity include respiratory depression and extreme
lethargy, while a rate of 14 breaths/minute and 2+ reflexes are within therapeutic
expectations.
3. A nurse is caring for a client in the first stage of labor and notes late decelerations on the
fetal heart rate monitor. Which of the following actions should the nurse take first?
A. Increase the rate of the oxytocin infusion
B. Prepare for an immediate vaginal exam
C. Assist the client into a side-lying position
D. Administer oxygen via a simple face mask at 2 L/min
Answer: C
Rationale: Late decelerations are caused by uteroplacental insufficiency and require
immediate nursing intervention. The first action is to improve placental blood flow by
positioning the client on her side to displace the uterus from the vena cava. Subsequent
, steps include discontinuing oxytocin, increasing IV fluids, and administering oxygen via a
non-rebreather mask at 8-10 L/min.
4. A postpartum nurse is assessing a client 2 hours after a vaginal delivery. The nurse finds the
fundus is boggy and displaced to the right. What is the priority nursing action?
A. Perform a fundal massage
B. Administer methylergonovine intramuscularly
C. Assist the client to the bathroom to void
D. Increase the IV oxytocin infusion rate
Answer: C
Rationale: A displaced fundus, especially to the right, is a classic sign of a full bladder
pushing the uterus out of position. A full bladder prevents the uterus from contracting
effectively, which significantly increases the risk of postpartum hemorrhage. Assisting the
client to empty her bladder allows the uterus to return to the midline and contract.
5. A nurse is reviewing the laboratory results for a client who is at 28 weeks of gestation.
Which of the following results should the nurse report to the provider?
A. Hemoglobin 11.5 g/dL
B. 1-hour glucose tolerance test 155 mg/dL
C. White blood cell count 12,000/mm3
D. Platelet count 160,000/mm3
