NSG 3500 MATERNAL HEALTH EXAM 2
GUIDE QUESTIONS AND ANSWERS
1. A nurse is caring for a client with preeclampsia who is receiving Magnesium Sulfate. Which
assessment finding should the nurse prioritize as a sign of toxicity?
A. Respiratory rate of 10 breaths/min
B. Deep tendon reflexes of 1+
C. Urine output of 40 mL/hr
D. Blood pressure of 150/95 mmHg
Answer: A
Conceptual Explanation: A respiratory rate below 12 breaths per minute is a critical sign
of magnesium toxicity, requiring immediate cessation of the infusion and administration of
calcium gluconate.
2. A laboring client’s fetal heart rate monitor shows late decelerations. Which action should
the nurse take first?
A. Administer oxygen via non-rebreather mask at 10 L/min
B. Increase the IV Pitocin infusion rate
,C. Assist the client into a supine position
D. Perform a vaginal exam to check for cord prolapse
Answer: A
Conceptual Explanation: Late decelerations indicate uteroplacental insufficiency.
Immediate interventions include lateral positioning, oxygen administration, and increasing
IV fluids; Pitocin should be discontinued, not increased.
3. A client at 32 weeks gestation presents with painless, bright red vaginal bleeding. Which
condition should the nurse suspect?
A. Placental abruption
B. Uterine rupture
C. Placenta previa
D. Preterm labor
Answer: C
Conceptual Explanation: Painless, bright red bleeding in the third trimester is a hallmark
sign of placenta previa, whereas placental abruption typically presents with painful, dark
red bleeding.
4. A nurse is reviewing the lab results of a client with suspected HELLP syndrome. Which
finding is consistent with this diagnosis?
A. Elevated hemoglobin
, B. Elevated platelets
C. Low hematocrit and low platelets
D. Decreased liver enzymes
Answer: C
Conceptual Explanation: HELLP stands for Hemolysis (low Hgb/Hct), Elevated Liver
enzymes, and Low Platelets. A low platelet count (under 100,000) is a primary indicator.
5. A client is receiving Oxytocin for labor induction. The nurse notes contractions occur every
90 seconds, lasting 70 seconds. What is the priority nursing action?
A. Turn the client to her left side
B. Discontinue the Oxytocin infusion
C. Check maternal blood pressure
D. Notify the provider to request an analgesic
Answer: B
Conceptual Explanation: Contractions occurring more frequently than every 2 minutes or
lasting longer than 90 seconds indicate tachysystole, which can lead to fetal distress. The
Oxytocin must be stopped immediately.
6. Which medication is contraindicated in a postpartum client with a history of asthma who is
experiencing hemorrhage?
A. Oxytocin
GUIDE QUESTIONS AND ANSWERS
1. A nurse is caring for a client with preeclampsia who is receiving Magnesium Sulfate. Which
assessment finding should the nurse prioritize as a sign of toxicity?
A. Respiratory rate of 10 breaths/min
B. Deep tendon reflexes of 1+
C. Urine output of 40 mL/hr
D. Blood pressure of 150/95 mmHg
Answer: A
Conceptual Explanation: A respiratory rate below 12 breaths per minute is a critical sign
of magnesium toxicity, requiring immediate cessation of the infusion and administration of
calcium gluconate.
2. A laboring client’s fetal heart rate monitor shows late decelerations. Which action should
the nurse take first?
A. Administer oxygen via non-rebreather mask at 10 L/min
B. Increase the IV Pitocin infusion rate
,C. Assist the client into a supine position
D. Perform a vaginal exam to check for cord prolapse
Answer: A
Conceptual Explanation: Late decelerations indicate uteroplacental insufficiency.
Immediate interventions include lateral positioning, oxygen administration, and increasing
IV fluids; Pitocin should be discontinued, not increased.
3. A client at 32 weeks gestation presents with painless, bright red vaginal bleeding. Which
condition should the nurse suspect?
A. Placental abruption
B. Uterine rupture
C. Placenta previa
D. Preterm labor
Answer: C
Conceptual Explanation: Painless, bright red bleeding in the third trimester is a hallmark
sign of placenta previa, whereas placental abruption typically presents with painful, dark
red bleeding.
4. A nurse is reviewing the lab results of a client with suspected HELLP syndrome. Which
finding is consistent with this diagnosis?
A. Elevated hemoglobin
, B. Elevated platelets
C. Low hematocrit and low platelets
D. Decreased liver enzymes
Answer: C
Conceptual Explanation: HELLP stands for Hemolysis (low Hgb/Hct), Elevated Liver
enzymes, and Low Platelets. A low platelet count (under 100,000) is a primary indicator.
5. A client is receiving Oxytocin for labor induction. The nurse notes contractions occur every
90 seconds, lasting 70 seconds. What is the priority nursing action?
A. Turn the client to her left side
B. Discontinue the Oxytocin infusion
C. Check maternal blood pressure
D. Notify the provider to request an analgesic
Answer: B
Conceptual Explanation: Contractions occurring more frequently than every 2 minutes or
lasting longer than 90 seconds indicate tachysystole, which can lead to fetal distress. The
Oxytocin must be stopped immediately.
6. Which medication is contraindicated in a postpartum client with a history of asthma who is
experiencing hemorrhage?
A. Oxytocin
