,NSG 340 Exam 4 – Obstetric and Maternity Nursing
– Grand Canyon University
1. A nurse is assessing a client at 28 weeks gestation who reports
sudden swelling in the face and hands, a headache, and blurred
vision. The nurse should suspect which condition?
A) Normal pregnancy symptoms
B) Gestational diabetes
C) Preeclampsia
D) Anemia
Correct Answer: Preeclampsia
Rationale: Sudden onset of facial and hand edema, headache, and
visual disturbances at 28 weeks gestation are classic signs of
preeclampsia. These symptoms require immediate evaluation for
hypertension and proteinuria. Normal pregnancy symptoms do not
include sudden, severe swelling or visual changes.
2. A client who is 36 weeks pregnant presents with painless vaginal
bleeding. The nurse suspects which complication?
A) Placental abruption
B) Placenta previa
C) Preterm labor
D) Rupture of membranes
,Correct Answer: Placenta previa
Rationale: Placenta previa is characterized by sudden, painless vaginal
bleeding in the third trimester. Placental abruption typically presents
with painful bleeding. Preterm labor and rupture of membranes are
not typically associated with painless bleeding.
3. A client with preeclampsia is receiving magnesium sulfate. Which
assessment finding indicates magnesium toxicity?
A) Respiratory rate of 16 breaths per minute
B) Absent deep tendon reflexes
C) Urine output of 40 mL per hour
D) Serum magnesium level of 5 mEq/L
Correct Answer: Absent deep tendon reflexes
Rationale: Magnesium sulfate toxicity is characterized by loss of deep
tendon reflexes (first sign), respiratory depression (rate < 12), and
cardiac arrest. The therapeutic serum magnesium level is 4–7 mEq/L.
Absent reflexes indicate toxicity and require immediate intervention.
4. Which medication is used to reverse the effects of magnesium
sulfate toxicity?
, A) Naloxone
B) Calcium gluconate
C) Vitamin K
D) Protamine sulfate
Correct Answer: Calcium gluconate
Rationale: Calcium gluconate is the antidote for magnesium sulfate
toxicity. It is administered intravenously to reverse the effects of
magnesium on the neuromuscular junction and cardiac conduction.
Naloxone reverses opioids, vitamin K reverses warfarin, and
protamine sulfate reverses heparin.
5. A nurse is caring for a client with a diagnosis of eclampsia. Which of
the following is the priority nursing intervention?
A) Administer magnesium sulfate and ensure a safe environment
B) Prepare for immediate delivery
C) Monitor blood pressure every hour
D) Administer antihypertensive medications
Correct Answer: Administer magnesium sulfate and ensure a safe
environment
– Grand Canyon University
1. A nurse is assessing a client at 28 weeks gestation who reports
sudden swelling in the face and hands, a headache, and blurred
vision. The nurse should suspect which condition?
A) Normal pregnancy symptoms
B) Gestational diabetes
C) Preeclampsia
D) Anemia
Correct Answer: Preeclampsia
Rationale: Sudden onset of facial and hand edema, headache, and
visual disturbances at 28 weeks gestation are classic signs of
preeclampsia. These symptoms require immediate evaluation for
hypertension and proteinuria. Normal pregnancy symptoms do not
include sudden, severe swelling or visual changes.
2. A client who is 36 weeks pregnant presents with painless vaginal
bleeding. The nurse suspects which complication?
A) Placental abruption
B) Placenta previa
C) Preterm labor
D) Rupture of membranes
,Correct Answer: Placenta previa
Rationale: Placenta previa is characterized by sudden, painless vaginal
bleeding in the third trimester. Placental abruption typically presents
with painful bleeding. Preterm labor and rupture of membranes are
not typically associated with painless bleeding.
3. A client with preeclampsia is receiving magnesium sulfate. Which
assessment finding indicates magnesium toxicity?
A) Respiratory rate of 16 breaths per minute
B) Absent deep tendon reflexes
C) Urine output of 40 mL per hour
D) Serum magnesium level of 5 mEq/L
Correct Answer: Absent deep tendon reflexes
Rationale: Magnesium sulfate toxicity is characterized by loss of deep
tendon reflexes (first sign), respiratory depression (rate < 12), and
cardiac arrest. The therapeutic serum magnesium level is 4–7 mEq/L.
Absent reflexes indicate toxicity and require immediate intervention.
4. Which medication is used to reverse the effects of magnesium
sulfate toxicity?
, A) Naloxone
B) Calcium gluconate
C) Vitamin K
D) Protamine sulfate
Correct Answer: Calcium gluconate
Rationale: Calcium gluconate is the antidote for magnesium sulfate
toxicity. It is administered intravenously to reverse the effects of
magnesium on the neuromuscular junction and cardiac conduction.
Naloxone reverses opioids, vitamin K reverses warfarin, and
protamine sulfate reverses heparin.
5. A nurse is caring for a client with a diagnosis of eclampsia. Which of
the following is the priority nursing intervention?
A) Administer magnesium sulfate and ensure a safe environment
B) Prepare for immediate delivery
C) Monitor blood pressure every hour
D) Administer antihypertensive medications
Correct Answer: Administer magnesium sulfate and ensure a safe
environment
