NUR 231 Exam 4 – Maternal Nursing Comprehensive Quiz 2026 UPDATE
1. A nurse is caring for a client in the second stage of labor. Which of the following
manifestations should the nurse expect?
A. The client is quiet and follows instructions easily.
B. The cervix is dilated from 0 to 3 cm.
C. The client experiences a strong urge to bear down.
D. The placental separation occurs.
Answer: C
Rationale: The second stage of labor begins with full cervical dilation (10 cm) and ends
with the birth of the baby; the primary characteristic is the urge to push or bear down.
2. When monitoring a fetal heart rate (FHR), the nurse notes late decelerations. Which action
should the nurse take first?
A. Increase the rate of oxytocin infusion.
B. Place the client in a supine position.
C. Perform a vaginal exam to check for cord prolapse.
D. Administer oxygen via a non-rebreather mask at 8-10 L/min.
Answer: D
,Rationale: Late decelerations indicate uteroplacental insufficiency. Immediate
interventions include repositioning the patient to the side, discontinuing oxytocin, and
administering oxygen to improve fetal oxygenation.
3. A client at 32 weeks gestation presents with painless, bright red vaginal bleeding. Which
condition should the nurse suspect?
A. Abruptio placentae
B. Molar pregnancy
C. Ectopic pregnancy
D. Placenta previa
Answer: D
Rationale: Placenta previa is characterized by painless, bright red vaginal bleeding during
the second or third trimester. Abruptio placentae usually involves painful, dark red
bleeding.
4. A nurse is monitoring a client receiving magnesium sulfate for preeclampsia. Which finding
is the most critical to report to the provider?
A. Feeling of warmth and flushing
B. Respiratory rate of 10/min
C. Urinary output of 40 mL/hr
D. Deep tendon reflexes of 2+
, Answer: B
Rationale: Magnesium sulfate toxicity causes central nervous system depression, leading
to respiratory depression (less than 12/min) and loss of deep tendon reflexes.
5. One hour after delivery, a nurse finds the client’s fundus to be boggy and displaced to the
right. What is the priority nursing action?
A. Massage the fundus until firm.
B. Notify the provider immediately.
C. Increase the IV fluid rate.
D. Assist the client to the bathroom to void.
Answer: D
Rationale: A fundus displaced to the right usually indicates a distended bladder, which
prevents the uterus from contracting. The priority is to empty the bladder.
6. Which APGAR score at 1 minute would require immediate resuscitation?
A. 9
B. 7
C. 5
D. 2
Answer: D
1. A nurse is caring for a client in the second stage of labor. Which of the following
manifestations should the nurse expect?
A. The client is quiet and follows instructions easily.
B. The cervix is dilated from 0 to 3 cm.
C. The client experiences a strong urge to bear down.
D. The placental separation occurs.
Answer: C
Rationale: The second stage of labor begins with full cervical dilation (10 cm) and ends
with the birth of the baby; the primary characteristic is the urge to push or bear down.
2. When monitoring a fetal heart rate (FHR), the nurse notes late decelerations. Which action
should the nurse take first?
A. Increase the rate of oxytocin infusion.
B. Place the client in a supine position.
C. Perform a vaginal exam to check for cord prolapse.
D. Administer oxygen via a non-rebreather mask at 8-10 L/min.
Answer: D
,Rationale: Late decelerations indicate uteroplacental insufficiency. Immediate
interventions include repositioning the patient to the side, discontinuing oxytocin, and
administering oxygen to improve fetal oxygenation.
3. A client at 32 weeks gestation presents with painless, bright red vaginal bleeding. Which
condition should the nurse suspect?
A. Abruptio placentae
B. Molar pregnancy
C. Ectopic pregnancy
D. Placenta previa
Answer: D
Rationale: Placenta previa is characterized by painless, bright red vaginal bleeding during
the second or third trimester. Abruptio placentae usually involves painful, dark red
bleeding.
4. A nurse is monitoring a client receiving magnesium sulfate for preeclampsia. Which finding
is the most critical to report to the provider?
A. Feeling of warmth and flushing
B. Respiratory rate of 10/min
C. Urinary output of 40 mL/hr
D. Deep tendon reflexes of 2+
, Answer: B
Rationale: Magnesium sulfate toxicity causes central nervous system depression, leading
to respiratory depression (less than 12/min) and loss of deep tendon reflexes.
5. One hour after delivery, a nurse finds the client’s fundus to be boggy and displaced to the
right. What is the priority nursing action?
A. Massage the fundus until firm.
B. Notify the provider immediately.
C. Increase the IV fluid rate.
D. Assist the client to the bathroom to void.
Answer: D
Rationale: A fundus displaced to the right usually indicates a distended bladder, which
prevents the uterus from contracting. The priority is to empty the bladder.
6. Which APGAR score at 1 minute would require immediate resuscitation?
A. 9
B. 7
C. 5
D. 2
Answer: D
