NSG 432 Exam 3 V1 | NSG 432 Maternal-
Newborn Nursing / OB/GYN | Actual Q&A
with Rationale (NSG432 Exam 3) | Grand
Canyon University
1. A nurse is assessing a patient at 34 weeks gestation who presents with severe headache
and blurred vision. Which of the following findings would the nurse expect to see in a patient
with severe preeclampsia? (Select all that apply)
A. Blood pressure of 165/112 mmHg
B. Blood pressure of 138/88 mmHg
C. 3+ protein in the urine via dipstick
D. Right upper quadrant epigastric pain
E. Polyuria exceeding 50 mL/hr
F. Platelet count of 90,000/mm3
Correct Answer: A, C, D, F
Severe preeclampsia is characterized by a blood pressure of 160/110 mmHg or higher
and evidence of end-organ dysfunction. Proteinuria of 3+ or greater and epigastric pain
indicating liver involvement are classic clinical manifestations. Thrombocytopenia, defined
as a platelet count less than 100,000, is also a diagnostic criterion for severe features.
,2. A patient is receiving Magnesium Sulfate for seizure prophylaxis. Which finding should the
nurse prioritize and report to the provider immediately?
A. Deep tendon reflexes of 2+
B. Urinary output of 40 mL per hour
C. Respiratory rate of 10 breaths per minute
D. Patient reporting feeling warm and flushed
Correct Answer: C
Magnesium Sulfate is a central nervous system depressant, and respiratory depression is a
sign of toxicity. A respiratory rate below 12 breaths per minute requires immediate
intervention and potential administration of calcium gluconate. Other signs of toxicity
include loss of deep tendon reflexes and significantly decreased urinary output.
3. A nurse is caring for a patient suspected of having a placental abruption. Which assessment
finding is most characteristic of this condition?
A. Painless, bright red vaginal bleeding
B. Abdominal pain with a board-like, rigid uterus
C. Soft, non-tender uterus
D. Fetal heart rate accelerations
Correct Answer: B
, Placental abruption involves the premature separation of the placenta from the uterine
wall, which typically causes significant pain and uterine tenderness. The accumulation of
blood between the placenta and the uterine wall leads to a rigid, board-like abdomen. In
contrast, placenta previa is typically characterized by painless, bright red bleeding.
4. What is the primary rationale for administering Betamethasone to a patient in preterm
labor at 30 weeks gestation?
A. To stop uterine contractions and delay delivery
B. To prevent Group B Streptococcus infection
C. To stimulate fetal surfactant production and promote lung maturity
D. To increase the maternal blood glucose levels for fetal energy
Correct Answer: C
Betamethasone is a corticosteroid administered to women at risk for preterm birth to
accelerate fetal lung development. It works by stimulating the production of surfactant,
which reduces the incidence of Respiratory Distress Syndrome in the neonate. The
medication is typically given in two doses, 24 hours apart, to achieve maximum
effectiveness.
5. A nurse is managing a patient on an Oxytocin (Pitocin) infusion for labor induction. The
nurse notes late decelerations on the fetal heart rate monitor. What is the priority nursing
action?
A. Discontinue the Oxytocin infusion immediately
, B. Increase the Oxytocin rate to speed up delivery
C. Perform a vaginal exam to check for cord prolapse
D. Place the patient in a supine position
Correct Answer: A
Late decelerations indicate uteroplacental insufficiency and are a sign of fetal distress. The
first action the nurse must take is to stop the Oxytocin infusion to decrease uterine activity
and improve fetal oxygenation. Following this, the nurse should reposition the patient to a
side-lying position and administer oxygen via non-rebreather mask.
6. During a vaginal delivery, the provider notes that the fetal head has emerged but retracted
against the perineum (turtle sign). Which maneuver should the nurse be prepared to assist
with first?
A. Fundal pressure
B. Zavanelli maneuver
C. Internal rotation (Woods Screw)
D. McRoberts maneuver
Correct Answer: D
The ‘turtle sign’ is a hallmark of shoulder dystocia, an emergency where the anterior
shoulder becomes stuck behind the symphysis pubis. The McRoberts maneuver involves
hyperflexing the mother’s legs to her chest, which flattens the sacrum and rotates the
Newborn Nursing / OB/GYN | Actual Q&A
with Rationale (NSG432 Exam 3) | Grand
Canyon University
1. A nurse is assessing a patient at 34 weeks gestation who presents with severe headache
and blurred vision. Which of the following findings would the nurse expect to see in a patient
with severe preeclampsia? (Select all that apply)
A. Blood pressure of 165/112 mmHg
B. Blood pressure of 138/88 mmHg
C. 3+ protein in the urine via dipstick
D. Right upper quadrant epigastric pain
E. Polyuria exceeding 50 mL/hr
F. Platelet count of 90,000/mm3
Correct Answer: A, C, D, F
Severe preeclampsia is characterized by a blood pressure of 160/110 mmHg or higher
and evidence of end-organ dysfunction. Proteinuria of 3+ or greater and epigastric pain
indicating liver involvement are classic clinical manifestations. Thrombocytopenia, defined
as a platelet count less than 100,000, is also a diagnostic criterion for severe features.
,2. A patient is receiving Magnesium Sulfate for seizure prophylaxis. Which finding should the
nurse prioritize and report to the provider immediately?
A. Deep tendon reflexes of 2+
B. Urinary output of 40 mL per hour
C. Respiratory rate of 10 breaths per minute
D. Patient reporting feeling warm and flushed
Correct Answer: C
Magnesium Sulfate is a central nervous system depressant, and respiratory depression is a
sign of toxicity. A respiratory rate below 12 breaths per minute requires immediate
intervention and potential administration of calcium gluconate. Other signs of toxicity
include loss of deep tendon reflexes and significantly decreased urinary output.
3. A nurse is caring for a patient suspected of having a placental abruption. Which assessment
finding is most characteristic of this condition?
A. Painless, bright red vaginal bleeding
B. Abdominal pain with a board-like, rigid uterus
C. Soft, non-tender uterus
D. Fetal heart rate accelerations
Correct Answer: B
, Placental abruption involves the premature separation of the placenta from the uterine
wall, which typically causes significant pain and uterine tenderness. The accumulation of
blood between the placenta and the uterine wall leads to a rigid, board-like abdomen. In
contrast, placenta previa is typically characterized by painless, bright red bleeding.
4. What is the primary rationale for administering Betamethasone to a patient in preterm
labor at 30 weeks gestation?
A. To stop uterine contractions and delay delivery
B. To prevent Group B Streptococcus infection
C. To stimulate fetal surfactant production and promote lung maturity
D. To increase the maternal blood glucose levels for fetal energy
Correct Answer: C
Betamethasone is a corticosteroid administered to women at risk for preterm birth to
accelerate fetal lung development. It works by stimulating the production of surfactant,
which reduces the incidence of Respiratory Distress Syndrome in the neonate. The
medication is typically given in two doses, 24 hours apart, to achieve maximum
effectiveness.
5. A nurse is managing a patient on an Oxytocin (Pitocin) infusion for labor induction. The
nurse notes late decelerations on the fetal heart rate monitor. What is the priority nursing
action?
A. Discontinue the Oxytocin infusion immediately
, B. Increase the Oxytocin rate to speed up delivery
C. Perform a vaginal exam to check for cord prolapse
D. Place the patient in a supine position
Correct Answer: A
Late decelerations indicate uteroplacental insufficiency and are a sign of fetal distress. The
first action the nurse must take is to stop the Oxytocin infusion to decrease uterine activity
and improve fetal oxygenation. Following this, the nurse should reposition the patient to a
side-lying position and administer oxygen via non-rebreather mask.
6. During a vaginal delivery, the provider notes that the fetal head has emerged but retracted
against the perineum (turtle sign). Which maneuver should the nurse be prepared to assist
with first?
A. Fundal pressure
B. Zavanelli maneuver
C. Internal rotation (Woods Screw)
D. McRoberts maneuver
Correct Answer: D
The ‘turtle sign’ is a hallmark of shoulder dystocia, an emergency where the anterior
shoulder becomes stuck behind the symphysis pubis. The McRoberts maneuver involves
hyperflexing the mother’s legs to her chest, which flattens the sacrum and rotates the
