NURS 254 MATERNAL EXAM 3 AND 4(MOTHER AND BABY) QUESTIONS AND DETAILED
CORRECT ANSWERS (ALREADY VERIFIED) AND GRADED A+
MATERNITY EXAMS 3 QUESTIONS AND ANSWERS
A woman is in the 2nd trimester of pregnancy. Her blood pressure is 148/92, she has edema of the
hands and feet, and her urine protein is 1+ dipstick. These data are indicative of:
a) mild preeclampsia
b) severe preeclampsia
c) HELLP syndrome
d) eclampsia
a) mild preeclampsia
A client with severe preeclampsia who has a BP of 170/110 mm Hg, a pulse of 108 bpm, and
respirations of 24 per minute is placed on IV magnesium sulfate therapy. 8 hours later her BP is
150/110, the pulse is 98, and respirations are 10, and there is absence of knee-jerk reflex. The nurse
should:
A) wait 1 hour, monitor vitals and reflexes again, and then, if necessary, discontinue the infusion
B) stop the infusion of mag sulfate and notify the physician
C) administer calcium gluconate as antidote for magnesium sulfate
D) continue the mag sulfate infusion because the BP is still high
B) stop the infusion of mag sulfate and notify the physician
a 28-year-old G2P0 preterm patient presents for observation admission at 30 weeks gestation, with a
change to her cervix 1 cm/40%/-1 since her last prenatal visit. Her care provider has ordered
Terbutaline 0.24 mg sq. What side effects from Terbutaline should you educate the patient about?
A) increased contractions
B) tremors or nervousness
C) hypoglycemia
D) Drowsiness
B) tremors or nervousness
A nurse is monitoring a client with PROM who is in labor and observes meconium in the amniotic
fluid. What does the observation of meconium indicate?
A) cord compression
B) fetal distress related to hypoxia
C) infection
D) CNS involvement
B) fetal distress related to hypoxia
,You're performing a head-to-toe assessment on a patient admitted with abruptio placentae. Which of
the following assessment findings would you immediately report to the physician?
A. Oozing around the IV site
B. Tender uterus
C. Hard abdomen
D. Vaginal bleeding
A. Oozing around the IV site
The answer is A. Oozing around the IV site can indicate the patient is entering into DIC (disseminated
intravascular coagulation) because clotting levels have been depleted. Therefore, the MD should be
notified. Option B, C, and D are findings found in this condition, but Option A is a SEVERE complication
that can develop from it.
Which statement is TRUE regarding abruptio placenta?
A. This condition occurs due to an abnormal attachment of the placenta in the uterus near or over the
cervical opening.
B. A marginal abruptio placenta occurs when the placenta is located near the edge of the cervical
opening.
C. Nursing interventions for this condition includes measuring the fundal height.
D. Fetal distress is not common in this condition as it is in placenta previa.
C. Nursing interventions for this condition includes measuring the fundal height.
Select all the signs and symptoms associated with placenta previa:
A. Painless bright red bleeding
B. Concealed bleeding
C. Hard, tender uterus
D. Normal fetal heart rate
E. Abnormal fetal position
F. Rigid abdomen
A. Painless bright red bleeding
D. Normal fetal heart rate
E. Abnormal fetal position
The answer is A, D, and E. These are all sign and symptoms of placenta previa. The other options are
associated abruptio placentae.
Disseminated intravascular coagulation (DIC) can occur in __________________. This happens because
when the placenta becomes damaged and detaches from the uterine wall, large amounts of
_____________ are released into mom's circulation, leading to clot formation and then clotting factor
,depletion.
A. Placenta previa, fibrinogen
B. Placenta previa, platelets
C. Abruptio placentae, fibrinogen
D. Abruptio placentae, thromboplastin
D. Abruptio placentae, thromboplastin
A patient who is 25 weeks pregnant has partial placenta previa. As the nurse you're educating the
patient about the condition and self-care. Which statement by the patient requires you to re-educate
the patient?
A. "I will avoid sexual intercourse and douching throughout the rest of the pregnancy."
B. "I may start to experience dark red bleeding with pain."
C. "I will have another ultrasound at 32 weeks to re-assess the placenta's location."
D. "My uterus should be soft and non-tender."
B. "I may start to experience dark red bleeding with pain."
The answer is B. All the other options are CORRECT about partial placenta previa. Option B is WRONG
because this condition will present with PAINLESS, bright red bleeding NOT with pain and dark red
bleeding, which happens in abruptio placentae.
The nurse knows that preeclampsia tends to occur during what time in a pregnancy? *
A. before 20 weeks
B. in the third trimester and postpartum
C. after 20 weeks
D. in the first and second trimester
C. after 20 weeks
A patient is currently 34 weeks pregnant with her first baby. Which findings below could indicate the
development of preeclampsia in this patient that would need to be reported to the physician? Select
all that apply:
A. 1600: blood pressure 144/100, 1700: blood pressure 120/80
B. 3+ dipstick urine protein
C. 1 hour glucose tolerance test 90 mg/dL
D. 0800: blood pressure 142/92, 1230: blood pressure: 144/98
E. <300 mg/dL 24-hour urine protein
B. 3+ dipstick urine protein
D. 0800: blood pressure 142/92, 1230: blood pressure: 144/98
, A woman in labor is at risk for abruptio placentae. Which of the following assessments would most
likely lead you to suspect that this has happened?
A) sharp fundal pain and discomfort between contractions
B) Painless vaginal bleeding and fall in blood pressure
C) pain in a lower quadrant and increased HR
D) an increased BP and oliguria
A) sharp fundal pain and discomfort between contractions
What is the pathophysiology responsible for a client who complains of a pounding headache and
elevated DTRs?
A) severe anxiety
B) increased perfusion to the brain
C) retinal arteriolar spasms
D) cerebral edema
D) cerebral edema
a 32 year old gravida 3 para 2 at 36 weeks' gestation comes to the obstetric department reporting
abdominal pain. Her BP is 164/90, her HR is 100 bpm, and her RR is 24 per minute. She is restless and
slightly diaphoretic with a small amount of dark red vaginal bleeding. What assessment should the
nurse make next?
A) check DTRs
B) measure fundal height
C) palpate the fundus and check FHR
D) obtain a voided urine specimen, and determine blood type
C) palpate the fundus and check FHR
A primigravida presents to labor and delivery at 36 weeks gestation complaining of severe uterine
tenderness and decreased fetal movement. What other clinical indicators would lead the nurse to
suspect abruptio placentae?
A) dark red vaginal bleeding and board like rigid abdomen
B) dark red vaginal bleeding and soft uterine resting tone
C) bright red vaginal bleeding and board like rigid abd
D) bright red vaginal bleeding and soft uterine resting tone
A) dark red vaginal bleeding and board like rigid abdomen
A preterm labor patient is receiving betamethasone. When the patient asks what this is for, the best
response by the nurse would be:
A) it will help reduce the severity of respiratory distress in your newborn
B) it is commonly used to prevent seizures
CORRECT ANSWERS (ALREADY VERIFIED) AND GRADED A+
MATERNITY EXAMS 3 QUESTIONS AND ANSWERS
A woman is in the 2nd trimester of pregnancy. Her blood pressure is 148/92, she has edema of the
hands and feet, and her urine protein is 1+ dipstick. These data are indicative of:
a) mild preeclampsia
b) severe preeclampsia
c) HELLP syndrome
d) eclampsia
a) mild preeclampsia
A client with severe preeclampsia who has a BP of 170/110 mm Hg, a pulse of 108 bpm, and
respirations of 24 per minute is placed on IV magnesium sulfate therapy. 8 hours later her BP is
150/110, the pulse is 98, and respirations are 10, and there is absence of knee-jerk reflex. The nurse
should:
A) wait 1 hour, monitor vitals and reflexes again, and then, if necessary, discontinue the infusion
B) stop the infusion of mag sulfate and notify the physician
C) administer calcium gluconate as antidote for magnesium sulfate
D) continue the mag sulfate infusion because the BP is still high
B) stop the infusion of mag sulfate and notify the physician
a 28-year-old G2P0 preterm patient presents for observation admission at 30 weeks gestation, with a
change to her cervix 1 cm/40%/-1 since her last prenatal visit. Her care provider has ordered
Terbutaline 0.24 mg sq. What side effects from Terbutaline should you educate the patient about?
A) increased contractions
B) tremors or nervousness
C) hypoglycemia
D) Drowsiness
B) tremors or nervousness
A nurse is monitoring a client with PROM who is in labor and observes meconium in the amniotic
fluid. What does the observation of meconium indicate?
A) cord compression
B) fetal distress related to hypoxia
C) infection
D) CNS involvement
B) fetal distress related to hypoxia
,You're performing a head-to-toe assessment on a patient admitted with abruptio placentae. Which of
the following assessment findings would you immediately report to the physician?
A. Oozing around the IV site
B. Tender uterus
C. Hard abdomen
D. Vaginal bleeding
A. Oozing around the IV site
The answer is A. Oozing around the IV site can indicate the patient is entering into DIC (disseminated
intravascular coagulation) because clotting levels have been depleted. Therefore, the MD should be
notified. Option B, C, and D are findings found in this condition, but Option A is a SEVERE complication
that can develop from it.
Which statement is TRUE regarding abruptio placenta?
A. This condition occurs due to an abnormal attachment of the placenta in the uterus near or over the
cervical opening.
B. A marginal abruptio placenta occurs when the placenta is located near the edge of the cervical
opening.
C. Nursing interventions for this condition includes measuring the fundal height.
D. Fetal distress is not common in this condition as it is in placenta previa.
C. Nursing interventions for this condition includes measuring the fundal height.
Select all the signs and symptoms associated with placenta previa:
A. Painless bright red bleeding
B. Concealed bleeding
C. Hard, tender uterus
D. Normal fetal heart rate
E. Abnormal fetal position
F. Rigid abdomen
A. Painless bright red bleeding
D. Normal fetal heart rate
E. Abnormal fetal position
The answer is A, D, and E. These are all sign and symptoms of placenta previa. The other options are
associated abruptio placentae.
Disseminated intravascular coagulation (DIC) can occur in __________________. This happens because
when the placenta becomes damaged and detaches from the uterine wall, large amounts of
_____________ are released into mom's circulation, leading to clot formation and then clotting factor
,depletion.
A. Placenta previa, fibrinogen
B. Placenta previa, platelets
C. Abruptio placentae, fibrinogen
D. Abruptio placentae, thromboplastin
D. Abruptio placentae, thromboplastin
A patient who is 25 weeks pregnant has partial placenta previa. As the nurse you're educating the
patient about the condition and self-care. Which statement by the patient requires you to re-educate
the patient?
A. "I will avoid sexual intercourse and douching throughout the rest of the pregnancy."
B. "I may start to experience dark red bleeding with pain."
C. "I will have another ultrasound at 32 weeks to re-assess the placenta's location."
D. "My uterus should be soft and non-tender."
B. "I may start to experience dark red bleeding with pain."
The answer is B. All the other options are CORRECT about partial placenta previa. Option B is WRONG
because this condition will present with PAINLESS, bright red bleeding NOT with pain and dark red
bleeding, which happens in abruptio placentae.
The nurse knows that preeclampsia tends to occur during what time in a pregnancy? *
A. before 20 weeks
B. in the third trimester and postpartum
C. after 20 weeks
D. in the first and second trimester
C. after 20 weeks
A patient is currently 34 weeks pregnant with her first baby. Which findings below could indicate the
development of preeclampsia in this patient that would need to be reported to the physician? Select
all that apply:
A. 1600: blood pressure 144/100, 1700: blood pressure 120/80
B. 3+ dipstick urine protein
C. 1 hour glucose tolerance test 90 mg/dL
D. 0800: blood pressure 142/92, 1230: blood pressure: 144/98
E. <300 mg/dL 24-hour urine protein
B. 3+ dipstick urine protein
D. 0800: blood pressure 142/92, 1230: blood pressure: 144/98
, A woman in labor is at risk for abruptio placentae. Which of the following assessments would most
likely lead you to suspect that this has happened?
A) sharp fundal pain and discomfort between contractions
B) Painless vaginal bleeding and fall in blood pressure
C) pain in a lower quadrant and increased HR
D) an increased BP and oliguria
A) sharp fundal pain and discomfort between contractions
What is the pathophysiology responsible for a client who complains of a pounding headache and
elevated DTRs?
A) severe anxiety
B) increased perfusion to the brain
C) retinal arteriolar spasms
D) cerebral edema
D) cerebral edema
a 32 year old gravida 3 para 2 at 36 weeks' gestation comes to the obstetric department reporting
abdominal pain. Her BP is 164/90, her HR is 100 bpm, and her RR is 24 per minute. She is restless and
slightly diaphoretic with a small amount of dark red vaginal bleeding. What assessment should the
nurse make next?
A) check DTRs
B) measure fundal height
C) palpate the fundus and check FHR
D) obtain a voided urine specimen, and determine blood type
C) palpate the fundus and check FHR
A primigravida presents to labor and delivery at 36 weeks gestation complaining of severe uterine
tenderness and decreased fetal movement. What other clinical indicators would lead the nurse to
suspect abruptio placentae?
A) dark red vaginal bleeding and board like rigid abdomen
B) dark red vaginal bleeding and soft uterine resting tone
C) bright red vaginal bleeding and board like rigid abd
D) bright red vaginal bleeding and soft uterine resting tone
A) dark red vaginal bleeding and board like rigid abdomen
A preterm labor patient is receiving betamethasone. When the patient asks what this is for, the best
response by the nurse would be:
A) it will help reduce the severity of respiratory distress in your newborn
B) it is commonly used to prevent seizures
