NUR 231 Exam 3 - Maternal Nursing 2026 UPDATED
1. A nurse is assessing a client in the active phase of labor. The client’s cervix is dilated to 5
cm, and the contractions are every 3 to 4 minutes. Which stage and phase of labor is the
client experiencing?
A. First stage, latent phase
B. Second stage, active phase
C. First stage, active phase
D. Third stage, latent phase
Answer: C
Rationale: The first stage of labor is divided into latent (0-3 cm), active (4-7 cm), and
transition (8-10 cm) phases. A dilation of 5 cm falls within the active phase.
2. Which fetal heart rate pattern is considered reassuring and indicates fetal well-being?
A. Late decelerations
B. Variable decelerations
C. Accelerations
D. Early decelerations
Answer: C
,Rationale: Accelerations are brief, temporary increases in the FHR and are a reassuring
sign of fetal well-being and an intact central nervous system.
3. A client at 34 weeks gestation presents with sudden, painless vaginal bleeding. What is the
most likely diagnosis?
A. Placental abruption
B. Preterm labor
C. Placenta previa
D. Uterine rupture
Answer: C
Rationale: Placenta previa is characterized by painless, bright red vaginal bleeding in the
second or third trimester.
4. Which medication is the antidote for magnesium sulfate toxicity?
A. Terbutaline
B. Naloxone
C. Calcium gluconate
D. Oxytocin
Answer: C
Rationale: Calcium gluconate is the specific antidote to reverse the effects of magnesium
sulfate toxicity, such as respiratory depression.
, 5. A nurse is caring for a client who is 2 hours postpartum and has a boggy uterus that is
displaced to the right. What is the priority nursing action?
A. Administer oxytocin
B. Massage the fundus
C. Notify the provider
D. Assist the client to void
Answer: D
Rationale: A uterus displaced to the right is usually caused by a full bladder. Assisting the
client to void allows the uterus to return to the midline and contract effectively.
6. What is the primary purpose of administering Vitamin K (phytonadione) to a newborn?
A. To prevent ophthalmia neonatorum
B. To promote blood clotting and prevent hemorrhage
C. To stimulate red blood cell production
D. To treat neonatal jaundice
Answer: B
Rationale: Newborns are born with low levels of Vitamin K because it does not cross the
placenta easily and the sterile gut hasn’t produced it yet. It is given to prevent hemorrhagic
disease.
1. A nurse is assessing a client in the active phase of labor. The client’s cervix is dilated to 5
cm, and the contractions are every 3 to 4 minutes. Which stage and phase of labor is the
client experiencing?
A. First stage, latent phase
B. Second stage, active phase
C. First stage, active phase
D. Third stage, latent phase
Answer: C
Rationale: The first stage of labor is divided into latent (0-3 cm), active (4-7 cm), and
transition (8-10 cm) phases. A dilation of 5 cm falls within the active phase.
2. Which fetal heart rate pattern is considered reassuring and indicates fetal well-being?
A. Late decelerations
B. Variable decelerations
C. Accelerations
D. Early decelerations
Answer: C
,Rationale: Accelerations are brief, temporary increases in the FHR and are a reassuring
sign of fetal well-being and an intact central nervous system.
3. A client at 34 weeks gestation presents with sudden, painless vaginal bleeding. What is the
most likely diagnosis?
A. Placental abruption
B. Preterm labor
C. Placenta previa
D. Uterine rupture
Answer: C
Rationale: Placenta previa is characterized by painless, bright red vaginal bleeding in the
second or third trimester.
4. Which medication is the antidote for magnesium sulfate toxicity?
A. Terbutaline
B. Naloxone
C. Calcium gluconate
D. Oxytocin
Answer: C
Rationale: Calcium gluconate is the specific antidote to reverse the effects of magnesium
sulfate toxicity, such as respiratory depression.
, 5. A nurse is caring for a client who is 2 hours postpartum and has a boggy uterus that is
displaced to the right. What is the priority nursing action?
A. Administer oxytocin
B. Massage the fundus
C. Notify the provider
D. Assist the client to void
Answer: D
Rationale: A uterus displaced to the right is usually caused by a full bladder. Assisting the
client to void allows the uterus to return to the midline and contract effectively.
6. What is the primary purpose of administering Vitamin K (phytonadione) to a newborn?
A. To prevent ophthalmia neonatorum
B. To promote blood clotting and prevent hemorrhage
C. To stimulate red blood cell production
D. To treat neonatal jaundice
Answer: B
Rationale: Newborns are born with low levels of Vitamin K because it does not cross the
placenta easily and the sterile gut hasn’t produced it yet. It is given to prevent hemorrhagic
disease.
