NSG 3500 MATERNAL HEALTH
NURSING PRACTICE GUIDE
QUESTIONS AND ANSWERS
1. A nurse is monitoring a client who is receiving magnesium sulfate for preeclampsia. Which
of the following findings should the nurse identify as a sign of magnesium toxicity?
A. Urine output of 40 mL/hr
B. Deep tendon reflexes of 2+
C. Respiratory rate of 10/min
D. Blood pressure of 150/100 mmHg
Answer: C
Conceptual Explanation: Signs of magnesium toxicity include a respiratory rate less than
12/min, absence of deep tendon reflexes, and urine output less than 30 mL/hr.
2. A client is in the first stage of labor and the fetal heart rate (FHR) monitor shows late
decelerations. Which of the following actions should the nurse take first?
A. Administer oxygen via face mask at 8-10 L/min
B. Turn the client onto her left side
,C. Increase the rate of the IV fluid infusion
D. Notify the healthcare provider
Answer: B
Conceptual Explanation: Late decelerations indicate uteroplacental insufficiency. The
priority action is to improve fetal oxygenation, which is best achieved by repositioning the
client to the side to relieve pressure on the vena cava.
3. A nurse is caring for a client who is at 38 weeks of gestation and reports sudden, dark red
vaginal bleeding and severe abdominal pain. The nurse should suspect which of the following
conditions?
A. Placenta previa
B. Vasa previa
C. Abruptio placentae
D. Hydatidiform mole
Answer: C
Conceptual Explanation: Abruptio placentae is characterized by painful, dark red vaginal
bleeding and a board-like, tender abdomen. Placenta previa usually presents as painless,
bright red bleeding.
, 4. A nurse is calculating a client’s expected date of delivery (EDD) using Nagele’s rule. The
client’s last menstrual period began on November 10th. What is the EDD?
A. February 17th
B. August 3rd
C. August 17th
D. August 10th
Answer: C
Conceptual Explanation: Nagele’s rule: Subtract 3 months and add 7 days to the first day
of the LMP. November 10 minus 3 months is August 10, plus 7 days is August 17.
5. Which of the following interventions is appropriate for a nurse to include in the plan of
care for a newborn receiving phototherapy for hyperbilirubinemia?
A. Keep the newborn’s eyes covered with a mask
B. Apply lotion to the newborn’s skin to prevent drying
C. Feed the newborn every 6 hours
D. Dress the newborn in a diaper and a t-shirt
Answer: A
Conceptual Explanation: Eye masks are essential to protect the newborn’s retinas from
the high-intensity light. Lotions should be avoided to prevent burns, and the newborn
should be dressed only in a diaper to maximize skin exposure.
NURSING PRACTICE GUIDE
QUESTIONS AND ANSWERS
1. A nurse is monitoring a client who is receiving magnesium sulfate for preeclampsia. Which
of the following findings should the nurse identify as a sign of magnesium toxicity?
A. Urine output of 40 mL/hr
B. Deep tendon reflexes of 2+
C. Respiratory rate of 10/min
D. Blood pressure of 150/100 mmHg
Answer: C
Conceptual Explanation: Signs of magnesium toxicity include a respiratory rate less than
12/min, absence of deep tendon reflexes, and urine output less than 30 mL/hr.
2. A client is in the first stage of labor and the fetal heart rate (FHR) monitor shows late
decelerations. Which of the following actions should the nurse take first?
A. Administer oxygen via face mask at 8-10 L/min
B. Turn the client onto her left side
,C. Increase the rate of the IV fluid infusion
D. Notify the healthcare provider
Answer: B
Conceptual Explanation: Late decelerations indicate uteroplacental insufficiency. The
priority action is to improve fetal oxygenation, which is best achieved by repositioning the
client to the side to relieve pressure on the vena cava.
3. A nurse is caring for a client who is at 38 weeks of gestation and reports sudden, dark red
vaginal bleeding and severe abdominal pain. The nurse should suspect which of the following
conditions?
A. Placenta previa
B. Vasa previa
C. Abruptio placentae
D. Hydatidiform mole
Answer: C
Conceptual Explanation: Abruptio placentae is characterized by painful, dark red vaginal
bleeding and a board-like, tender abdomen. Placenta previa usually presents as painless,
bright red bleeding.
, 4. A nurse is calculating a client’s expected date of delivery (EDD) using Nagele’s rule. The
client’s last menstrual period began on November 10th. What is the EDD?
A. February 17th
B. August 3rd
C. August 17th
D. August 10th
Answer: C
Conceptual Explanation: Nagele’s rule: Subtract 3 months and add 7 days to the first day
of the LMP. November 10 minus 3 months is August 10, plus 7 days is August 17.
5. Which of the following interventions is appropriate for a nurse to include in the plan of
care for a newborn receiving phototherapy for hyperbilirubinemia?
A. Keep the newborn’s eyes covered with a mask
B. Apply lotion to the newborn’s skin to prevent drying
C. Feed the newborn every 6 hours
D. Dress the newborn in a diaper and a t-shirt
Answer: A
Conceptual Explanation: Eye masks are essential to protect the newborn’s retinas from
the high-intensity light. Lotions should be avoided to prevent burns, and the newborn
should be dressed only in a diaper to maximize skin exposure.
