NSG 3500 Exam 4 V3 | NSG 3500 Maternal
Health Review | Actual Q&A with
Rationale (NSG3500 Exam 4) | Galen
College of Nursing
1. A nurse is assessing a client 2 hours postpartum and finds the fundus to be boggy and
displaced to the right. What is the priority nursing intervention?
A. Perform fundal massage immediately.
B. Assist the client to the bathroom to void.
C. Administer oxytocin as ordered.
D. Notify the healthcare provider of potential hemorrhage.
Answer: B
Rationale: A fundus that is displaced to the right is a classic sign of bladder distention. A
full bladder prevents the uterus from contracting effectively, which can lead to atony and
hemorrhage. Emptying the bladder is the priority to allow the fundus to return to the
midline and firm up.
2. A postpartum patient with a history of asthma is experiencing excessive vaginal bleeding.
Which medication should the nurse expect the provider to avoid?
A. Oxytocin (Pitocin)
B. Methylergonovine (Methergine)
,C. Misoprostol (Cytotec)
D. Carboprost Tromethamine (Hemabate)
Answer: D
Rationale: Carboprost (Hemabate) is a prostaglandin that can cause significant
bronchoconstriction. Therefore, it is contraindicated in patients with a history of asthma or
respiratory disease. The nurse should advocate for alternative uterotonics to manage
postpartum hemorrhage in this patient.
3. Which assessment finding in a newborn requires immediate intervention by the nurse?
A. Acrocyanosis of the hands and feet.
B. Erythema toxicum on the trunk.
C. Heart rate of 140 beats per minute.
D. Nasal flaring and chest retractions.
Answer: D
Rationale: Nasal flaring and retractions are clinical signs of respiratory distress in the
neonate. While acrocyanosis is normal in the first 24 hours, respiratory effort should be
quiet and easy. Failure to intervene may lead to hypoxia and respiratory failure.
4. A nurse is teaching a mother about breastfeeding. Which statement by the mother
indicates an understanding of the LATCH assessment tool?
A. I should only breastfeed for 10 minutes on each side.
, B. I should hear audible swallowing while the baby is nursing.
C. The baby’s nose should be pressed tightly against my breast.
D. Lanolin should be applied to the nipple before every feeding.
Answer: B
Rationale: The ‘A’ in the LATCH score stands for Audible swallowing, which indicates
successful milk transfer. Hearing the baby swallow ensures that the latch is functional and
the baby is receiving colostrum or milk. This is a key indicator of breastfeeding efficacy
used in clinical practice.
5. A client is receiving Magnesium Sulfate for preeclampsia. The nurse notes a respiratory
rate of 10 and absent deep tendon reflexes. What is the priority action?
A. Increase the IV fluid rate.
B. Place the client in a Trendelenburg position.
C. Discontinue the Magnesium Sulfate infusion.
D. Administer oxygen via nasal cannula.
Answer: C
Rationale: Bradypnea and absent reflexes are signs of magnesium toxicity. The first action
is to stop the infusion to prevent further toxicity. The nurse would then prepare to
administer calcium gluconate as the antidote.
Health Review | Actual Q&A with
Rationale (NSG3500 Exam 4) | Galen
College of Nursing
1. A nurse is assessing a client 2 hours postpartum and finds the fundus to be boggy and
displaced to the right. What is the priority nursing intervention?
A. Perform fundal massage immediately.
B. Assist the client to the bathroom to void.
C. Administer oxytocin as ordered.
D. Notify the healthcare provider of potential hemorrhage.
Answer: B
Rationale: A fundus that is displaced to the right is a classic sign of bladder distention. A
full bladder prevents the uterus from contracting effectively, which can lead to atony and
hemorrhage. Emptying the bladder is the priority to allow the fundus to return to the
midline and firm up.
2. A postpartum patient with a history of asthma is experiencing excessive vaginal bleeding.
Which medication should the nurse expect the provider to avoid?
A. Oxytocin (Pitocin)
B. Methylergonovine (Methergine)
,C. Misoprostol (Cytotec)
D. Carboprost Tromethamine (Hemabate)
Answer: D
Rationale: Carboprost (Hemabate) is a prostaglandin that can cause significant
bronchoconstriction. Therefore, it is contraindicated in patients with a history of asthma or
respiratory disease. The nurse should advocate for alternative uterotonics to manage
postpartum hemorrhage in this patient.
3. Which assessment finding in a newborn requires immediate intervention by the nurse?
A. Acrocyanosis of the hands and feet.
B. Erythema toxicum on the trunk.
C. Heart rate of 140 beats per minute.
D. Nasal flaring and chest retractions.
Answer: D
Rationale: Nasal flaring and retractions are clinical signs of respiratory distress in the
neonate. While acrocyanosis is normal in the first 24 hours, respiratory effort should be
quiet and easy. Failure to intervene may lead to hypoxia and respiratory failure.
4. A nurse is teaching a mother about breastfeeding. Which statement by the mother
indicates an understanding of the LATCH assessment tool?
A. I should only breastfeed for 10 minutes on each side.
, B. I should hear audible swallowing while the baby is nursing.
C. The baby’s nose should be pressed tightly against my breast.
D. Lanolin should be applied to the nipple before every feeding.
Answer: B
Rationale: The ‘A’ in the LATCH score stands for Audible swallowing, which indicates
successful milk transfer. Hearing the baby swallow ensures that the latch is functional and
the baby is receiving colostrum or milk. This is a key indicator of breastfeeding efficacy
used in clinical practice.
5. A client is receiving Magnesium Sulfate for preeclampsia. The nurse notes a respiratory
rate of 10 and absent deep tendon reflexes. What is the priority action?
A. Increase the IV fluid rate.
B. Place the client in a Trendelenburg position.
C. Discontinue the Magnesium Sulfate infusion.
D. Administer oxygen via nasal cannula.
Answer: C
Rationale: Bradypnea and absent reflexes are signs of magnesium toxicity. The first action
is to stop the infusion to prevent further toxicity. The nurse would then prepare to
administer calcium gluconate as the antidote.
