NUR 230 OB/PEDS COMPREHENSIVE
EXAMINATION QUESTIONS AND
ANSWERS
1. A nurse is caring for a client receiving magnesium sulfate for preeclampsia. Which of the
following findings should the nurse report to the provider as an early sign of toxicity?
A. Urinary output of 40 mL/hr
B. Respiratory rate of 10 breaths per minute
C. Deep tendon reflexes of 1+
D. Blood pressure of 150/90 mmHg
Answer: B
Conceptual Explanation: Respiratory depression (less than 12/min) is a critical sign of
magnesium sulfate toxicity and requires immediate intervention, including potentially the
administration of calcium gluconate.
2. A client at 32 weeks of gestation is admitted with painless, bright red vaginal bleeding.
Which of the following actions should the nurse avoid?
A. Assessing maternal blood pressure
B. Monitoring fetal heart rate
,C. Performing a vaginal examination
D. Initiating IV access
Answer: C
Conceptual Explanation: Painless bright red bleeding suggests placenta previa. A vaginal
exam is strictly contraindicated because it can cause catastrophic hemorrhage by
puncturing the placenta.
3. A nurse is interpreting a fetal heart rate (FHR) tracing and notes late decelerations. Which
of the following is the priority nursing action?
A. Administer oxygen via nasal cannula at 2 L/min.
B. Increase the oxytocin infusion rate.
C. Document the finding as a normal response to labor.
D. Assist the client into a side-lying position.
Answer: D
Conceptual Explanation: Late decelerations indicate uteroplacental insufficiency.
Repositioning the client to the lateral side-lying position is the first step to improve
placental blood flow and oxygenation to the fetus.
, 4. A client is in the first stage of labor and is 9 cm dilated. She reports a feeling of intense
pressure and the urge to push. Which of the following phases of labor is the client
experiencing?
A. Latent phase
B. Transition phase
C. Active phase
D. Second stage
Answer: B
Conceptual Explanation: The transition phase occurs when the cervix is 8-10 cm dilated.
It is characterized by intense pressure, nausea, and the urge to push, even before full
dilation.
5. Which of the following medications is administered to a newborn within 1 to 2 hours of
birth to prevent hemorrhagic disease?
A. Vitamin K (Phytonadione)
B. Hepatitis B vaccine
C. Erythromycin ointment
D. Inactivated Poliovirus Vaccine
Answer: A
EXAMINATION QUESTIONS AND
ANSWERS
1. A nurse is caring for a client receiving magnesium sulfate for preeclampsia. Which of the
following findings should the nurse report to the provider as an early sign of toxicity?
A. Urinary output of 40 mL/hr
B. Respiratory rate of 10 breaths per minute
C. Deep tendon reflexes of 1+
D. Blood pressure of 150/90 mmHg
Answer: B
Conceptual Explanation: Respiratory depression (less than 12/min) is a critical sign of
magnesium sulfate toxicity and requires immediate intervention, including potentially the
administration of calcium gluconate.
2. A client at 32 weeks of gestation is admitted with painless, bright red vaginal bleeding.
Which of the following actions should the nurse avoid?
A. Assessing maternal blood pressure
B. Monitoring fetal heart rate
,C. Performing a vaginal examination
D. Initiating IV access
Answer: C
Conceptual Explanation: Painless bright red bleeding suggests placenta previa. A vaginal
exam is strictly contraindicated because it can cause catastrophic hemorrhage by
puncturing the placenta.
3. A nurse is interpreting a fetal heart rate (FHR) tracing and notes late decelerations. Which
of the following is the priority nursing action?
A. Administer oxygen via nasal cannula at 2 L/min.
B. Increase the oxytocin infusion rate.
C. Document the finding as a normal response to labor.
D. Assist the client into a side-lying position.
Answer: D
Conceptual Explanation: Late decelerations indicate uteroplacental insufficiency.
Repositioning the client to the lateral side-lying position is the first step to improve
placental blood flow and oxygenation to the fetus.
, 4. A client is in the first stage of labor and is 9 cm dilated. She reports a feeling of intense
pressure and the urge to push. Which of the following phases of labor is the client
experiencing?
A. Latent phase
B. Transition phase
C. Active phase
D. Second stage
Answer: B
Conceptual Explanation: The transition phase occurs when the cervix is 8-10 cm dilated.
It is characterized by intense pressure, nausea, and the urge to push, even before full
dilation.
5. Which of the following medications is administered to a newborn within 1 to 2 hours of
birth to prevent hemorrhagic disease?
A. Vitamin K (Phytonadione)
B. Hepatitis B vaccine
C. Erythromycin ointment
D. Inactivated Poliovirus Vaccine
Answer: A
