NR327/NR 327 Exam 2 V1 | Maternal Child Nursing
Q&A with Rationale | Chamberlain University
1. A nurse is caring for a client with severe preeclampsia who is receiving magnesium sulfate.
Which assessment finding should the nurse report to the provider immediately?
A. Urinary output of 40 mL per hour
B. Respiratory rate of 10 breaths per minute
C. Deep tendon reflexes of 2+
D. Blood pressure of 150/95 mmHg
Correct Answer: B
Explanation: A respiratory rate below 12 breaths per minute is a classic sign of
magnesium sulfate toxicity. Magnesium sulfate acts as a central nervous system depressant,
and toxicity can lead to respiratory arrest. The nurse must immediately stop the infusion
and notify the provider while preparing the antidote, calcium gluconate.
2. A client at 32 weeks of gestation presents with painless, bright red vaginal bleeding. Which
action by the nurse is contraindicated?
A. Obtaining a blood sample for hemoglobin and hematocrit
B. Applying an external fetal monitor
C. Starting a large-bore intravenous line
D. Performing a sterile vaginal examination
,Correct Answer: D
Explanation: Painless bright red bleeding is indicative of placenta previa. Performing a
vaginal examination could disrupt the placenta and cause catastrophic hemorrhage.
Diagnosis is confirmed via ultrasound, and all vaginal assessments are strictly prohibited
until the placental location is known.
3. A nurse is monitoring a client in active labor and notes variable decelerations on the fetal
heart rate monitor. What is the priority nursing intervention?
A. Administer oxygen at 10 L/min via a non-rebreather mask
B. Increase the rate of the maintenance intravenous fluids
C. Reposition the client to a side-lying or knee-chest position
D. Prepare for an immediate vacuum-assisted delivery
Correct Answer: C
Explanation: Variable decelerations are typically caused by umbilical cord compression.
Changing the client’s position is the first step to alleviate pressure on the cord. If the
decelerations persist, further interventions like oxygen administration or amnioinfusion
may be considered.
4. A client at 38 weeks of gestation is diagnosed with a placental abruption. Which finding
should the nurse expect to assess?
A. Soft, non-tender abdomen
B. Painless vaginal bleeding
, C. Board-like, rigid abdomen
D. Relaxed uterine tone
Correct Answer: C
Explanation: Placental abruption involves the premature separation of the placenta from
the uterine wall, leading to internal bleeding. This causes the uterus to become rigid, board-
like, and extremely tender to palpation. Unlike placenta previa, abruption is usually
associated with significant abdominal pain.
5. A nurse is caring for a client in labor who is receiving oxytocin. The nurse notes
contractions occur every 90 seconds and last for 80 seconds. What is the nurse’s priority
action?
A. Decrease the oxytocin infusion rate by half
B. Administer a tocolytic medication as prescribed
C. Notify the provider of the contraction pattern
D. Discontinue the oxytocin infusion immediately
Correct Answer: D
Explanation: The client is experiencing uterine tachysystole, which is defined as more than
five contractions in 10 minutes or contractions occurring less than 2 minutes apart.
Tachysystole can lead to fetal hypoxia due to inadequate resting time for placental
perfusion. The priority action is to stop the oxytocin to allow the uterus to relax.
Q&A with Rationale | Chamberlain University
1. A nurse is caring for a client with severe preeclampsia who is receiving magnesium sulfate.
Which assessment finding should the nurse report to the provider immediately?
A. Urinary output of 40 mL per hour
B. Respiratory rate of 10 breaths per minute
C. Deep tendon reflexes of 2+
D. Blood pressure of 150/95 mmHg
Correct Answer: B
Explanation: A respiratory rate below 12 breaths per minute is a classic sign of
magnesium sulfate toxicity. Magnesium sulfate acts as a central nervous system depressant,
and toxicity can lead to respiratory arrest. The nurse must immediately stop the infusion
and notify the provider while preparing the antidote, calcium gluconate.
2. A client at 32 weeks of gestation presents with painless, bright red vaginal bleeding. Which
action by the nurse is contraindicated?
A. Obtaining a blood sample for hemoglobin and hematocrit
B. Applying an external fetal monitor
C. Starting a large-bore intravenous line
D. Performing a sterile vaginal examination
,Correct Answer: D
Explanation: Painless bright red bleeding is indicative of placenta previa. Performing a
vaginal examination could disrupt the placenta and cause catastrophic hemorrhage.
Diagnosis is confirmed via ultrasound, and all vaginal assessments are strictly prohibited
until the placental location is known.
3. A nurse is monitoring a client in active labor and notes variable decelerations on the fetal
heart rate monitor. What is the priority nursing intervention?
A. Administer oxygen at 10 L/min via a non-rebreather mask
B. Increase the rate of the maintenance intravenous fluids
C. Reposition the client to a side-lying or knee-chest position
D. Prepare for an immediate vacuum-assisted delivery
Correct Answer: C
Explanation: Variable decelerations are typically caused by umbilical cord compression.
Changing the client’s position is the first step to alleviate pressure on the cord. If the
decelerations persist, further interventions like oxygen administration or amnioinfusion
may be considered.
4. A client at 38 weeks of gestation is diagnosed with a placental abruption. Which finding
should the nurse expect to assess?
A. Soft, non-tender abdomen
B. Painless vaginal bleeding
, C. Board-like, rigid abdomen
D. Relaxed uterine tone
Correct Answer: C
Explanation: Placental abruption involves the premature separation of the placenta from
the uterine wall, leading to internal bleeding. This causes the uterus to become rigid, board-
like, and extremely tender to palpation. Unlike placenta previa, abruption is usually
associated with significant abdominal pain.
5. A nurse is caring for a client in labor who is receiving oxytocin. The nurse notes
contractions occur every 90 seconds and last for 80 seconds. What is the nurse’s priority
action?
A. Decrease the oxytocin infusion rate by half
B. Administer a tocolytic medication as prescribed
C. Notify the provider of the contraction pattern
D. Discontinue the oxytocin infusion immediately
Correct Answer: D
Explanation: The client is experiencing uterine tachysystole, which is defined as more than
five contractions in 10 minutes or contractions occurring less than 2 minutes apart.
Tachysystole can lead to fetal hypoxia due to inadequate resting time for placental
perfusion. The priority action is to stop the oxytocin to allow the uterus to relax.
