NSG 3500 Exam 4 V2 | NSG 3500 Maternal
Health Review | Actual Q&A with
Rationale (NSG3500 Exam 4) | Galen
College of Nursing
1. A nurse is assessing a client in the fourth stage of labor and notes the fundus is firm, but
there is a continuous trickle of bright red blood. What is the most likely cause of this
bleeding?
A. Uterine atony
B. Disseminated intravascular coagulation (DIC)
C. Retained placental fragments
D. Laceration of the genital tract
Answer: D
Rationale: A firm fundus with continuous bleeding suggests a laceration rather than atony.
Uterine atony would present with a boggy fundus, which is the primary cause of PPH. The
nurse must report this finding immediately as it requires surgical repair.
2. A nurse is caring for a client receiving magnesium sulfate for preeclampsia. Which
assessment finding should the nurse report as a sign of magnesium toxicity?
A. Blood pressure of 150/95 mmHg
B. Respiratory rate of 10 breaths per minute
,C. Deep tendon reflexes of 2+
D. Urinary output of 40 mL per hour
Answer: B
Rationale: Magnesium sulfate is a central nervous system depressant, and toxicity can
cause respiratory depression. A respiratory rate below 12 breaths per minute is a critical
sign of toxicity. The nurse must also monitor for loss of deep tendon reflexes and decreased
urinary output below 30 mL/hr.
3. Which fetal heart rate pattern should the nurse identify as being caused by umbilical cord
compression?
A. Variable decelerations
B. Late decelerations
C. Early decelerations
D. Accelerations
Answer: A
Rationale: Variable decelerations are abrupt decreases in fetal heart rate and are typically
associated with cord compression. This differs from early decelerations, which are caused
by head compression, and late decelerations, which indicate uteroplacental insufficiency.
Corrective actions include repositioning the mother to relieve pressure on the cord.
, 4. A newborn has a heart rate of 110, a slow/weak cry, some flexion of extremities, is
grimacing when stimulated, and has a pink body with blue extremities. What is the APGAR
score?
A. 5
B. 7
C. 6
D. 8
Answer: C
Rationale: The score is calculated as follows: Heart rate >100 (2), slow cry (1), flexion (1),
grimace (1), and acrocyanosis (1). This totals 6, which indicates a need for some
intervention or close monitoring. APGAR scores are traditionally taken at 1 and 5 minutes
after birth.
5. Which medication is typically administered to the newborn within 1 hour of birth to
prevent ophthalmia neonatorum?
A. Vitamin K
B. Erythromycin ophthalmic ointment
C. Hepatitis B vaccine
D. Triple dye
Answer: B
Health Review | Actual Q&A with
Rationale (NSG3500 Exam 4) | Galen
College of Nursing
1. A nurse is assessing a client in the fourth stage of labor and notes the fundus is firm, but
there is a continuous trickle of bright red blood. What is the most likely cause of this
bleeding?
A. Uterine atony
B. Disseminated intravascular coagulation (DIC)
C. Retained placental fragments
D. Laceration of the genital tract
Answer: D
Rationale: A firm fundus with continuous bleeding suggests a laceration rather than atony.
Uterine atony would present with a boggy fundus, which is the primary cause of PPH. The
nurse must report this finding immediately as it requires surgical repair.
2. A nurse is caring for a client receiving magnesium sulfate for preeclampsia. Which
assessment finding should the nurse report as a sign of magnesium toxicity?
A. Blood pressure of 150/95 mmHg
B. Respiratory rate of 10 breaths per minute
,C. Deep tendon reflexes of 2+
D. Urinary output of 40 mL per hour
Answer: B
Rationale: Magnesium sulfate is a central nervous system depressant, and toxicity can
cause respiratory depression. A respiratory rate below 12 breaths per minute is a critical
sign of toxicity. The nurse must also monitor for loss of deep tendon reflexes and decreased
urinary output below 30 mL/hr.
3. Which fetal heart rate pattern should the nurse identify as being caused by umbilical cord
compression?
A. Variable decelerations
B. Late decelerations
C. Early decelerations
D. Accelerations
Answer: A
Rationale: Variable decelerations are abrupt decreases in fetal heart rate and are typically
associated with cord compression. This differs from early decelerations, which are caused
by head compression, and late decelerations, which indicate uteroplacental insufficiency.
Corrective actions include repositioning the mother to relieve pressure on the cord.
, 4. A newborn has a heart rate of 110, a slow/weak cry, some flexion of extremities, is
grimacing when stimulated, and has a pink body with blue extremities. What is the APGAR
score?
A. 5
B. 7
C. 6
D. 8
Answer: C
Rationale: The score is calculated as follows: Heart rate >100 (2), slow cry (1), flexion (1),
grimace (1), and acrocyanosis (1). This totals 6, which indicates a need for some
intervention or close monitoring. APGAR scores are traditionally taken at 1 and 5 minutes
after birth.
5. Which medication is typically administered to the newborn within 1 hour of birth to
prevent ophthalmia neonatorum?
A. Vitamin K
B. Erythromycin ophthalmic ointment
C. Hepatitis B vaccine
D. Triple dye
Answer: B
