NSG 432 Final Exam V2 | NSG 432
Maternal-Newborn Nursing / OB/GYN |
Actual Q&A with Rationale (NSG432 Final
Exam) | Grand Canyon University
1. A nurse is assessing a client at 34 weeks gestation who presents with suspected
preeclampsia. Which of the following findings should the nurse document as clinical
manifestations of this condition? (Select all that apply)
A. Visual disturbances such as blurred vision or flashing lights
B. Epigastric or right upper quadrant pain
C. Hyporeflexia and decreased deep tendon reflexes
D. Persistent headache that does not respond to analgesics
E. Proteinuria verified by a 24-hour urine collection
F. Increased urinary output above 50 mL per hour
Correct Answer: A, B, D, E
Preeclampsia is characterized by hypertension and multi-organ involvement after 20
weeks of gestation. Clinical manifestations include severe headaches, visual changes, and
epigastric pain which indicates liver involvement. Proteinuria is a classic diagnostic
marker, while hyporeflexia and polyuria are typically not associated with this condition;
rather, hyperreflexia is a concern for seizure activity.
,2. A nurse is caring for a client in the first stage of labor. The fetal heart rate monitor shows
late decelerations. Which of the following actions should the nurse take first?
A. Increase the rate of the maintenance IV infusion
B. Reposition the client into a side-lying lateral position
C. Perform a vaginal examination to check for cord prolapse
D. Administer oxygen at 2 L/min via nasal cannula
Correct Answer: B
Late decelerations indicate uteroplacental insufficiency and require immediate
intervention to improve oxygenation. The first step in intrauterine resuscitation is to
change the maternal position to relieve pressure on the inferior vena cava and improve
blood flow. Other interventions include increasing IV fluids and administering 8-10 L of
oxygen via non-rebreather mask, but positioning is the priority action.
3. A postpartum nurse is assessing a client 2 hours after a vaginal delivery. The client’s fundus
is boggy and displaced to the right of the midline. Which of the following actions should the
nurse take?
A. Massage the fundus until it is firm
B. Notify the provider of a possible uterine inversion
C. Administer oxytocin as prescribed by the provider
D. Assist the client to the bathroom to void
,Correct Answer: D
A fundus that is displaced to the right and is boggy usually indicates a distended bladder,
which prevents the uterus from contracting effectively. Assisting the client to empty her
bladder is the most appropriate first action to allow the uterus to return to the midline and
firm up. While fundal massage is important, it will not be effective if the bladder remains
full and continues to displace the uterus.
4. A nurse is teaching a newly licensed nurse about the administration of Rho(D) immune
globulin. Which of the following clients should receive this medication?
A. An Rh-positive mother who delivered an Rh-negative newborn
B. An Rh-negative mother who just had a miscarriage at 10 weeks gestation
C. An Rh-positive mother with a positive indirect Coombs test
D. An Rh-negative mother who delivered an Rh-positive newborn and is Coombs negative
Correct Answer: D
Rho(D) immune globulin is administered to Rh-negative mothers who are not sensitized
(Coombs negative) to prevent the formation of antibodies against Rh-positive fetal blood.
This medication is given routinely at 28 weeks gestation and within 72 hours of delivery if
the newborn is Rh-positive. Rh-positive mothers do not require this treatment regardless
of the newborn’s blood type.
, 5. A nurse is performing a newborn assessment 1 hour after birth. Which of the following
findings is a manifestation of respiratory distress in the neonate?
A. A respiratory rate of 50 breaths per minute
B. Nasal flaring and substernal retractions
C. Acrocyanosis of the hands and feet
D. Brief periods of apnea lasting less than 10 seconds
Correct Answer: B
Nasal flaring, grunting, and retractions are hallmark signs of respiratory distress in a
newborn and require immediate evaluation. A normal newborn respiratory rate is between
30 and 60 breaths per minute, and acrocyanosis is a normal finding in the first 24 to 48
hours. Short periods of periodic breathing or apnea under 15 seconds are considered
normal as long as they are not accompanied by color changes or bradycardia.
6. A client at 38 weeks gestation is admitted with heavy, painful vaginal bleeding and a
board-like abdomen. The nurse should suspect which of the following conditions?
A. Placenta previa
B. Hydatidiform mole
C. Cervical insufficiency
D. Abruptio placentae
Correct Answer: D
Maternal-Newborn Nursing / OB/GYN |
Actual Q&A with Rationale (NSG432 Final
Exam) | Grand Canyon University
1. A nurse is assessing a client at 34 weeks gestation who presents with suspected
preeclampsia. Which of the following findings should the nurse document as clinical
manifestations of this condition? (Select all that apply)
A. Visual disturbances such as blurred vision or flashing lights
B. Epigastric or right upper quadrant pain
C. Hyporeflexia and decreased deep tendon reflexes
D. Persistent headache that does not respond to analgesics
E. Proteinuria verified by a 24-hour urine collection
F. Increased urinary output above 50 mL per hour
Correct Answer: A, B, D, E
Preeclampsia is characterized by hypertension and multi-organ involvement after 20
weeks of gestation. Clinical manifestations include severe headaches, visual changes, and
epigastric pain which indicates liver involvement. Proteinuria is a classic diagnostic
marker, while hyporeflexia and polyuria are typically not associated with this condition;
rather, hyperreflexia is a concern for seizure activity.
,2. A nurse is caring for a client in the first stage of labor. The fetal heart rate monitor shows
late decelerations. Which of the following actions should the nurse take first?
A. Increase the rate of the maintenance IV infusion
B. Reposition the client into a side-lying lateral position
C. Perform a vaginal examination to check for cord prolapse
D. Administer oxygen at 2 L/min via nasal cannula
Correct Answer: B
Late decelerations indicate uteroplacental insufficiency and require immediate
intervention to improve oxygenation. The first step in intrauterine resuscitation is to
change the maternal position to relieve pressure on the inferior vena cava and improve
blood flow. Other interventions include increasing IV fluids and administering 8-10 L of
oxygen via non-rebreather mask, but positioning is the priority action.
3. A postpartum nurse is assessing a client 2 hours after a vaginal delivery. The client’s fundus
is boggy and displaced to the right of the midline. Which of the following actions should the
nurse take?
A. Massage the fundus until it is firm
B. Notify the provider of a possible uterine inversion
C. Administer oxytocin as prescribed by the provider
D. Assist the client to the bathroom to void
,Correct Answer: D
A fundus that is displaced to the right and is boggy usually indicates a distended bladder,
which prevents the uterus from contracting effectively. Assisting the client to empty her
bladder is the most appropriate first action to allow the uterus to return to the midline and
firm up. While fundal massage is important, it will not be effective if the bladder remains
full and continues to displace the uterus.
4. A nurse is teaching a newly licensed nurse about the administration of Rho(D) immune
globulin. Which of the following clients should receive this medication?
A. An Rh-positive mother who delivered an Rh-negative newborn
B. An Rh-negative mother who just had a miscarriage at 10 weeks gestation
C. An Rh-positive mother with a positive indirect Coombs test
D. An Rh-negative mother who delivered an Rh-positive newborn and is Coombs negative
Correct Answer: D
Rho(D) immune globulin is administered to Rh-negative mothers who are not sensitized
(Coombs negative) to prevent the formation of antibodies against Rh-positive fetal blood.
This medication is given routinely at 28 weeks gestation and within 72 hours of delivery if
the newborn is Rh-positive. Rh-positive mothers do not require this treatment regardless
of the newborn’s blood type.
, 5. A nurse is performing a newborn assessment 1 hour after birth. Which of the following
findings is a manifestation of respiratory distress in the neonate?
A. A respiratory rate of 50 breaths per minute
B. Nasal flaring and substernal retractions
C. Acrocyanosis of the hands and feet
D. Brief periods of apnea lasting less than 10 seconds
Correct Answer: B
Nasal flaring, grunting, and retractions are hallmark signs of respiratory distress in a
newborn and require immediate evaluation. A normal newborn respiratory rate is between
30 and 60 breaths per minute, and acrocyanosis is a normal finding in the first 24 to 48
hours. Short periods of periodic breathing or apnea under 15 seconds are considered
normal as long as they are not accompanied by color changes or bradycardia.
6. A client at 38 weeks gestation is admitted with heavy, painful vaginal bleeding and a
board-like abdomen. The nurse should suspect which of the following conditions?
A. Placenta previa
B. Hydatidiform mole
C. Cervical insufficiency
D. Abruptio placentae
Correct Answer: D
