NSG 3500 Exam 2 V2 | NSG 3500 Maternal Health
Review | Actual Q&A with Rationale (NSG3500
Exam 2) | Galen College of Nursing
1. A nurse is caring for a client who is in the first stage of labor and has a fetal heart rate (FHR)
tracing showing late decelerations. Which of the following actions should the nurse take first?
A. Administer oxygen at 8 to 10 L/min via nonrebreather mask.
B. Assist the client into a lateral position.
C. Increase the rate of the maintenance IV fluid infusion.
D. Notify the primary healthcare provider.
Correct Answer: B
Explanation: Late decelerations are caused by uteroplacental insufficiency and indicate
fetal distress. The first priority in the intrauterine resuscitation protocol is to reposition the
client to a side-lying position to improve blood flow to the placenta. While oxygen
administration and IV fluid boluses are also standard interventions, changing the mother’s
position is the most immediate action to alleviate pressure on the vena cava and enhance
perfusion.
2. A nurse is monitoring a client receiving Magnesium Sulfate for preeclampsia. Which of the
following findings should the nurse identify as a manifestation of magnesium toxicity?
A. Respiratory rate of 10 breaths per minute.
B. Presence of 2+ deep tendon reflexes (DTRs).
,C. Increased urine output of 40 mL/hr.
D. Blood pressure of 150/90 mmHg.
Correct Answer: A
Explanation: A respiratory rate below 12 breaths per minute is a classic sign of
magnesium sulfate toxicity due to CNS depression. The nurse should also monitor for the
loss of deep tendon reflexes and a significant decrease in urinary output, specifically less
than 30 mL/hr. If toxicity is suspected, the infusion must be stopped immediately and the
antidote, calcium gluconate, should be readily available.
3. A client at 34 weeks gestation presents with sudden-onset, severe abdominal pain and a
rigid, board-like abdomen. The nurse suspects which of the following conditions?
A. Placenta previa
B. Hydatidiform mole
C. Abruptio placentae
D. Ectopic pregnancy
Correct Answer: C
Explanation: Abruptio placentae involves the premature separation of the placenta from
the uterine wall and is characterized by painful vaginal bleeding and abdominal rigidity.
Unlike placenta previa, which presents with painless bright red bleeding, abruption causes
internal or external hemorrhage and significant uterine tenderness. This is a medical
,emergency that requires immediate assessment of fetal well-being and maternal
hemodynamic stability.
4. Which of the following medications is administered to a client in preterm labor to promote
fetal lung maturity?
A. Terbutaline
B. Magnesium Sulfate
C. Betamethasone
D. Indomethacin
Correct Answer: C
Explanation: Betamethasone is a glucocorticoid administered to clients between 24 and
34 weeks of gestation who are at risk for preterm delivery. The medication stimulates the
production of surfactant in the fetal lungs, which reduces the incidence of respiratory
distress syndrome (RDS) in the neonate. Typically, two doses are given intramuscularly 24
hours apart for maximum effectiveness.
5. A nurse is assessing a client who is 2 hours postpartum and observes that the fundus is
boggy and displaced to the right. Which of the following is the priority nursing action?
A. Massage the fundus until firm.
B. Administer oxytocin as prescribed.
C. Assist the client to empty her bladder.
, D. Notify the healthcare provider of the displacement.
Correct Answer: C
Explanation: A fundus that is displaced to the right is a characteristic sign of a distended
bladder. A full bladder prevents the uterus from contracting effectively, which significantly
increases the risk of postpartum hemorrhage. After the client voids, the nurse should
reassess the fundus and provide massage if it remains boggy.
6. A nurse is caring for a newborn immediately following birth. Which of the following actions
should the nurse perform first?
A. Dry the newborn and provide a warm environment.
B. Apply erythromycin ophthalmic ointment.
C. Administer the Vitamin K injection.
D. Perform the initial APGAR assessment.
Correct Answer: A
Explanation: Newborns are highly susceptible to heat loss through evaporation and
convection, leading to cold stress. The priority action is to dry the infant immediately and
place them under a radiant warmer or skin-to-skin with the mother to maintain
thermoregulation. Once the infant is stable and warm, other interventions like medication
administration and detailed assessments can be completed.
Review | Actual Q&A with Rationale (NSG3500
Exam 2) | Galen College of Nursing
1. A nurse is caring for a client who is in the first stage of labor and has a fetal heart rate (FHR)
tracing showing late decelerations. Which of the following actions should the nurse take first?
A. Administer oxygen at 8 to 10 L/min via nonrebreather mask.
B. Assist the client into a lateral position.
C. Increase the rate of the maintenance IV fluid infusion.
D. Notify the primary healthcare provider.
Correct Answer: B
Explanation: Late decelerations are caused by uteroplacental insufficiency and indicate
fetal distress. The first priority in the intrauterine resuscitation protocol is to reposition the
client to a side-lying position to improve blood flow to the placenta. While oxygen
administration and IV fluid boluses are also standard interventions, changing the mother’s
position is the most immediate action to alleviate pressure on the vena cava and enhance
perfusion.
2. A nurse is monitoring a client receiving Magnesium Sulfate for preeclampsia. Which of the
following findings should the nurse identify as a manifestation of magnesium toxicity?
A. Respiratory rate of 10 breaths per minute.
B. Presence of 2+ deep tendon reflexes (DTRs).
,C. Increased urine output of 40 mL/hr.
D. Blood pressure of 150/90 mmHg.
Correct Answer: A
Explanation: A respiratory rate below 12 breaths per minute is a classic sign of
magnesium sulfate toxicity due to CNS depression. The nurse should also monitor for the
loss of deep tendon reflexes and a significant decrease in urinary output, specifically less
than 30 mL/hr. If toxicity is suspected, the infusion must be stopped immediately and the
antidote, calcium gluconate, should be readily available.
3. A client at 34 weeks gestation presents with sudden-onset, severe abdominal pain and a
rigid, board-like abdomen. The nurse suspects which of the following conditions?
A. Placenta previa
B. Hydatidiform mole
C. Abruptio placentae
D. Ectopic pregnancy
Correct Answer: C
Explanation: Abruptio placentae involves the premature separation of the placenta from
the uterine wall and is characterized by painful vaginal bleeding and abdominal rigidity.
Unlike placenta previa, which presents with painless bright red bleeding, abruption causes
internal or external hemorrhage and significant uterine tenderness. This is a medical
,emergency that requires immediate assessment of fetal well-being and maternal
hemodynamic stability.
4. Which of the following medications is administered to a client in preterm labor to promote
fetal lung maturity?
A. Terbutaline
B. Magnesium Sulfate
C. Betamethasone
D. Indomethacin
Correct Answer: C
Explanation: Betamethasone is a glucocorticoid administered to clients between 24 and
34 weeks of gestation who are at risk for preterm delivery. The medication stimulates the
production of surfactant in the fetal lungs, which reduces the incidence of respiratory
distress syndrome (RDS) in the neonate. Typically, two doses are given intramuscularly 24
hours apart for maximum effectiveness.
5. A nurse is assessing a client who is 2 hours postpartum and observes that the fundus is
boggy and displaced to the right. Which of the following is the priority nursing action?
A. Massage the fundus until firm.
B. Administer oxytocin as prescribed.
C. Assist the client to empty her bladder.
, D. Notify the healthcare provider of the displacement.
Correct Answer: C
Explanation: A fundus that is displaced to the right is a characteristic sign of a distended
bladder. A full bladder prevents the uterus from contracting effectively, which significantly
increases the risk of postpartum hemorrhage. After the client voids, the nurse should
reassess the fundus and provide massage if it remains boggy.
6. A nurse is caring for a newborn immediately following birth. Which of the following actions
should the nurse perform first?
A. Dry the newborn and provide a warm environment.
B. Apply erythromycin ophthalmic ointment.
C. Administer the Vitamin K injection.
D. Perform the initial APGAR assessment.
Correct Answer: A
Explanation: Newborns are highly susceptible to heat loss through evaporation and
convection, leading to cold stress. The priority action is to dry the infant immediately and
place them under a radiant warmer or skin-to-skin with the mother to maintain
thermoregulation. Once the infant is stable and warm, other interventions like medication
administration and detailed assessments can be completed.
