, Question 1
A laboring client receiving oxytocin has tachysystole with recurrent late
decelerations. After discontinuing oxytocin and repositioning, the FHR
remains Category III. Which action should the nurse anticipate next?
A. Administer terbutaline subcutaneously and prepare for emergent
cesarean birth.
B. Increase IV fluid rate and continue monitoring for 30 minutes.
C. Apply fetal scalp electrode and obtain fetal blood sample.
D. Restart oxytocin at half dose to maintain labor progress.
Correct Answer: A - Administer terbutaline subcutaneously and
prepare for emergent cesarean birth.
RATIONALE
Category III tracing with recurrent late decelerations unresponsive to
intrauterine resuscitation indicates acute fetal hypoxia; terbutaline to
reduce uterine activity and preparation for emergent delivery are
indicated. Continuing monitoring or restarting oxytocin delays
necessary intervention, and fetal scalp stimulation is not appropriate in
a Category III pattern requiring immediate delivery.
Question 2
Which finding in a client at 34 weeks' gestation with severe preeclampsia most
strongly indicates imminent eclampsia and warrants magnesium sulfate
infusion?
A. Blood pressure 158/102 mm Hg
B. 3+ proteinuria on dipstick
C. Hyperreflexia with clonus and frontal headache
D. Serum creatinine 1.1 mg/dL
Correct Answer: C - Hyperreflexia with clonus and frontal
headache
Page 2
, RATIONALE
Hyperreflexia with clonus and persistent frontal headache reflect CNS
irritability from cerebral edema, the strongest predictor of impending
seizures, making magnesium sulfate indicated. Hypertension and
proteinuria are diagnostic but not the best imminent-seizure indicator,
and mild creatinine elevation indicates renal involvement without the
same immediate seizure risk.
Question 3
A client receiving magnesium sulfate for preeclampsia has a respiratory rate of
11/min, absent deep tendon reflexes, and urine output of 20 mL/hr. Which is
the priority nursing action?
A. Increase the magnesium infusion to maintain therapeutic levels.
B. Stop the infusion and prepare to administer calcium gluconate.
C. Administer furosemide to promote magnesium excretion.
D. Document findings and reassess in one hour.
Correct Answer: B - Stop the infusion and prepare to administer
calcium gluconate.
RATIONALE
These findings indicate magnesium toxicity; the infusion must be
stopped immediately and calcium gluconate given as the antidote.
Increasing the infusion worsens toxicity, furosemide is not the
antidote and may worsen renal function, and delayed reassessment
risks respiratory arrest.
Question 4
Which assessment finding in a client 24 hours postpartum after a spontaneous
vaginal birth most urgently requires provider notification?
A. Fundus firm at umbilicus, lochia rubra moderate
B. Temperature 100.4°F (38°C) oral
C. Saturating a perineal pad in 15 minutes with a boggy fundus
Page 3
A laboring client receiving oxytocin has tachysystole with recurrent late
decelerations. After discontinuing oxytocin and repositioning, the FHR
remains Category III. Which action should the nurse anticipate next?
A. Administer terbutaline subcutaneously and prepare for emergent
cesarean birth.
B. Increase IV fluid rate and continue monitoring for 30 minutes.
C. Apply fetal scalp electrode and obtain fetal blood sample.
D. Restart oxytocin at half dose to maintain labor progress.
Correct Answer: A - Administer terbutaline subcutaneously and
prepare for emergent cesarean birth.
RATIONALE
Category III tracing with recurrent late decelerations unresponsive to
intrauterine resuscitation indicates acute fetal hypoxia; terbutaline to
reduce uterine activity and preparation for emergent delivery are
indicated. Continuing monitoring or restarting oxytocin delays
necessary intervention, and fetal scalp stimulation is not appropriate in
a Category III pattern requiring immediate delivery.
Question 2
Which finding in a client at 34 weeks' gestation with severe preeclampsia most
strongly indicates imminent eclampsia and warrants magnesium sulfate
infusion?
A. Blood pressure 158/102 mm Hg
B. 3+ proteinuria on dipstick
C. Hyperreflexia with clonus and frontal headache
D. Serum creatinine 1.1 mg/dL
Correct Answer: C - Hyperreflexia with clonus and frontal
headache
Page 2
, RATIONALE
Hyperreflexia with clonus and persistent frontal headache reflect CNS
irritability from cerebral edema, the strongest predictor of impending
seizures, making magnesium sulfate indicated. Hypertension and
proteinuria are diagnostic but not the best imminent-seizure indicator,
and mild creatinine elevation indicates renal involvement without the
same immediate seizure risk.
Question 3
A client receiving magnesium sulfate for preeclampsia has a respiratory rate of
11/min, absent deep tendon reflexes, and urine output of 20 mL/hr. Which is
the priority nursing action?
A. Increase the magnesium infusion to maintain therapeutic levels.
B. Stop the infusion and prepare to administer calcium gluconate.
C. Administer furosemide to promote magnesium excretion.
D. Document findings and reassess in one hour.
Correct Answer: B - Stop the infusion and prepare to administer
calcium gluconate.
RATIONALE
These findings indicate magnesium toxicity; the infusion must be
stopped immediately and calcium gluconate given as the antidote.
Increasing the infusion worsens toxicity, furosemide is not the
antidote and may worsen renal function, and delayed reassessment
risks respiratory arrest.
Question 4
Which assessment finding in a client 24 hours postpartum after a spontaneous
vaginal birth most urgently requires provider notification?
A. Fundus firm at umbilicus, lochia rubra moderate
B. Temperature 100.4°F (38°C) oral
C. Saturating a perineal pad in 15 minutes with a boggy fundus
Page 3
