NSG 3500 MATERNAL HEALTH EXAM 3
PRACTICE GUIDE QUESTIONS AND
ANSWERS
1. A nurse is monitoring a client receiving magnesium sulfate for preeclampsia. Which finding
is the most sensitive early indicator of magnesium toxicity?
A. Respiratory rate of 14 breaths/min
B. Urinary output of 30 mL/hr
C. Disappearance of deep tendon reflexes
D. Serum magnesium level of 6 mg/dL
Answer: C
Conceptual Explanation: The loss of patellar or deep tendon reflexes is the earliest clinical
sign of magnesium toxicity. Respiratory depression and cardiac arrest occur at higher
levels.
2. A client at 34 weeks gestation presents with sudden, dark red vaginal bleeding and a
board-like, tender abdomen. What is the nurse’s priority action?
A. Perform a sterile vaginal exam to check dilation
,B. Assess the fundal height for growth
C. Administer Rho(D) immune globulin
D. Initiate continuous fetal heart rate monitoring
Answer: D
Conceptual Explanation: The symptoms suggest placental abruption. Monitoring the fetal
status is a priority to detect distress, alongside maternal stabilization. Vaginal exams are
contraindicated until placenta previa is ruled out.
3. During the second stage of labor, a nurse notes a pattern of fetal heart rate decelerations
that vary in timing, shape, and intensity with no relation to contractions. Which intervention
is most appropriate?
A. Administer oxygen via non-rebreather mask at 10 L/min
B. Reposition the client to a side-lying or knee-chest position
C. Increase the IV Pitocin infusion rate
D. Prepare for immediate forceps-assisted delivery
Answer: B
Conceptual Explanation: Variable decelerations are caused by umbilical cord
compression. The first action is to change the maternal position to relieve pressure on the
cord.
, 4. A postpartum nurse is caring for a client who had a vaginal delivery 2 hours ago. The
fundus is boggy and displaced to the right. What is the primary nursing action?
A. Assist the client to the bathroom to void
B. Administer oxytocin 20 units IM
C. Massage the fundus until firm
D. Notify the provider of a potential hemorrhage
Answer: A
Conceptual Explanation: A fundus displaced to the right usually indicates a full bladder,
which prevents the uterus from contracting. Emptying the bladder is the priority to allow
the fundus to return to the midline and firm up.
5. A nurse is assessing a newborn 1 minute after birth. The heart rate is 110 bpm, the infant
has a weak cry, some flexion of extremities, grimace in response to suctioning, and a pink
body with blue extremities. What is the Apgar score?
A. 5
B. 8
C. 7
D. 6
Answer: D
PRACTICE GUIDE QUESTIONS AND
ANSWERS
1. A nurse is monitoring a client receiving magnesium sulfate for preeclampsia. Which finding
is the most sensitive early indicator of magnesium toxicity?
A. Respiratory rate of 14 breaths/min
B. Urinary output of 30 mL/hr
C. Disappearance of deep tendon reflexes
D. Serum magnesium level of 6 mg/dL
Answer: C
Conceptual Explanation: The loss of patellar or deep tendon reflexes is the earliest clinical
sign of magnesium toxicity. Respiratory depression and cardiac arrest occur at higher
levels.
2. A client at 34 weeks gestation presents with sudden, dark red vaginal bleeding and a
board-like, tender abdomen. What is the nurse’s priority action?
A. Perform a sterile vaginal exam to check dilation
,B. Assess the fundal height for growth
C. Administer Rho(D) immune globulin
D. Initiate continuous fetal heart rate monitoring
Answer: D
Conceptual Explanation: The symptoms suggest placental abruption. Monitoring the fetal
status is a priority to detect distress, alongside maternal stabilization. Vaginal exams are
contraindicated until placenta previa is ruled out.
3. During the second stage of labor, a nurse notes a pattern of fetal heart rate decelerations
that vary in timing, shape, and intensity with no relation to contractions. Which intervention
is most appropriate?
A. Administer oxygen via non-rebreather mask at 10 L/min
B. Reposition the client to a side-lying or knee-chest position
C. Increase the IV Pitocin infusion rate
D. Prepare for immediate forceps-assisted delivery
Answer: B
Conceptual Explanation: Variable decelerations are caused by umbilical cord
compression. The first action is to change the maternal position to relieve pressure on the
cord.
, 4. A postpartum nurse is caring for a client who had a vaginal delivery 2 hours ago. The
fundus is boggy and displaced to the right. What is the primary nursing action?
A. Assist the client to the bathroom to void
B. Administer oxytocin 20 units IM
C. Massage the fundus until firm
D. Notify the provider of a potential hemorrhage
Answer: A
Conceptual Explanation: A fundus displaced to the right usually indicates a full bladder,
which prevents the uterus from contracting. Emptying the bladder is the priority to allow
the fundus to return to the midline and firm up.
5. A nurse is assessing a newborn 1 minute after birth. The heart rate is 110 bpm, the infant
has a weak cry, some flexion of extremities, grimace in response to suctioning, and a pink
body with blue extremities. What is the Apgar score?
A. 5
B. 8
C. 7
D. 6
Answer: D
