NURS 306 Final Quiz V1 | NURS 306 OB |
Actual Q&A with Rationale (NURS306
Final Quiz) | West Coast University
1. A nurse is monitoring a client who is receiving magnesium sulfate via IV infusion for
preeclampsia. Which of the following findings should the nurse report to the provider as a
sign of toxicity?
A. Absence of deep tendon reflexes
B. Urinary output of 40 mL/hr
C. Respiratory rate of 16/min
D. Blood pressure of 145/95 mmHg
Answer: A
Rationale: The loss of deep tendon reflexes is one of the earliest signs of magnesium
sulfate toxicity. It indicates that the magnesium levels are becoming dangerously high and
depressing the central nervous system. The nurse must immediately stop the infusion and
prepare to administer calcium gluconate if this occurs.
2. A nurse is reviewing a fetal heart rate tracing and notes late decelerations. Which of the
following actions should the nurse take first?
A. Increase the IV oxytocin infusion rate
B. Perform a vaginal exam to check for cord prolapse
,C. Prepare for an immediate vaginal delivery
D. Reposition the client to a side-lying position
Answer: D
Rationale: Late decelerations are caused by uteroplacental insufficiency and are
considered a non-reassuring sign. Repositioning the client to the lateral position is the
priority action to improve uterine blood flow. The nurse should also provide oxygen via
face mask and discontinue oxytocin if it is being administered.
3. A client who is 2 hours postpartum has a boggy fundus that is displaced to the right. Which
of the following actions should the nurse take?
A. Administer oxytocin
B. Perform a fundal massage
C. Notify the provider immediately
D. Assist the client to the bathroom to void
Answer: D
Rationale: A fundus that is displaced to the right and is boggy usually indicates a full
bladder. A distended bladder prevents the uterus from contracting efficiently, increasing
the risk of hemorrhage. Emptying the bladder allows the uterus to return to the midline
and contract firmly.
, 4. A nurse is assessing a newborn 1 minute after birth. The newborn has a heart rate of
110/min, a weak cry, some flexion of the extremities, grimaces when stimulated, and is pale
pink. What is the APGAR score?
A. 4
B. 5
C. 6
D. 7
Answer: C
Rationale: The score is calculated as follows: Heart rate > 100 (2 points), Weak
cry/respiratory effort (1 point), Muscle tone/some flexion (1 point), Reflex
irritability/grimace (1 point), Color/pale pink body (1 point). This totals 6 points. APGAR
scores below 7 often require closer observation or intervention.
5. A nurse is caring for a client in the active phase of labor. The client’s cervix is dilated to 5
cm and contractions are every 3 minutes. Which of the following is an appropriate nursing
intervention?
A. Encourage the client to use breathing techniques
B. Prepare for immediate delivery
C. Advise the client to begin pushing
D. Perform a sterile vaginal exam every 15 minutes
Actual Q&A with Rationale (NURS306
Final Quiz) | West Coast University
1. A nurse is monitoring a client who is receiving magnesium sulfate via IV infusion for
preeclampsia. Which of the following findings should the nurse report to the provider as a
sign of toxicity?
A. Absence of deep tendon reflexes
B. Urinary output of 40 mL/hr
C. Respiratory rate of 16/min
D. Blood pressure of 145/95 mmHg
Answer: A
Rationale: The loss of deep tendon reflexes is one of the earliest signs of magnesium
sulfate toxicity. It indicates that the magnesium levels are becoming dangerously high and
depressing the central nervous system. The nurse must immediately stop the infusion and
prepare to administer calcium gluconate if this occurs.
2. A nurse is reviewing a fetal heart rate tracing and notes late decelerations. Which of the
following actions should the nurse take first?
A. Increase the IV oxytocin infusion rate
B. Perform a vaginal exam to check for cord prolapse
,C. Prepare for an immediate vaginal delivery
D. Reposition the client to a side-lying position
Answer: D
Rationale: Late decelerations are caused by uteroplacental insufficiency and are
considered a non-reassuring sign. Repositioning the client to the lateral position is the
priority action to improve uterine blood flow. The nurse should also provide oxygen via
face mask and discontinue oxytocin if it is being administered.
3. A client who is 2 hours postpartum has a boggy fundus that is displaced to the right. Which
of the following actions should the nurse take?
A. Administer oxytocin
B. Perform a fundal massage
C. Notify the provider immediately
D. Assist the client to the bathroom to void
Answer: D
Rationale: A fundus that is displaced to the right and is boggy usually indicates a full
bladder. A distended bladder prevents the uterus from contracting efficiently, increasing
the risk of hemorrhage. Emptying the bladder allows the uterus to return to the midline
and contract firmly.
, 4. A nurse is assessing a newborn 1 minute after birth. The newborn has a heart rate of
110/min, a weak cry, some flexion of the extremities, grimaces when stimulated, and is pale
pink. What is the APGAR score?
A. 4
B. 5
C. 6
D. 7
Answer: C
Rationale: The score is calculated as follows: Heart rate > 100 (2 points), Weak
cry/respiratory effort (1 point), Muscle tone/some flexion (1 point), Reflex
irritability/grimace (1 point), Color/pale pink body (1 point). This totals 6 points. APGAR
scores below 7 often require closer observation or intervention.
5. A nurse is caring for a client in the active phase of labor. The client’s cervix is dilated to 5
cm and contractions are every 3 minutes. Which of the following is an appropriate nursing
intervention?
A. Encourage the client to use breathing techniques
B. Prepare for immediate delivery
C. Advise the client to begin pushing
D. Perform a sterile vaginal exam every 15 minutes
