NUR 254 Maternal & Pediatric Nursing
Exam 3: High-Risk Obstetrics & Newborn Care
Galen College of Nursing | Latest Verified A+ Guide
Question 1
A pregnant patient at 34 weeks gestation is admitted with a blood pressure of 160/110
mmHg, 3+ proteinuria, and severe edema. While the nurse is obtaining the history, the
patient begins to experience a tonic - clonic seizure. What is the nurse's PRIORITY
ac tion?
A) Administer oxytocin to induce labor
B) Protect the patient from injury, maintain a patent airway, and prepare to administer
Magnesium Sulfate
C) Immediately draw blood for a complete metabolic panel
D) Place the patient in a prone position to prev ent aspiration
**Answer: B) Protect the patient from injury, maintain a patent airway, and prepare to
administer Magnesium Sulfate**
**Rationale:** This patient has progressed from severe preeclampsia to **eclampsia**
(preeclampsia + seizures). The immediate priority during an active seizure is safety:
prevent injury (padded side rails, remove objects), protect the airway (turn to side if
possible, suction available), and administer the ordered IV loading dose of Magnesium
Sulfate to stop the seizure. Oxyt ocin is not a priority during an active seizure. Prone
position is contraindicated in pregnancy and impedes the airway.
, ---
### Question 2
A patient with severe preeclampsia is receiving an intravenous infusion of Magnesium
Sulfate. Which of the following assessment findings requires the nurse to STOP the
infusion IMMEDIATELY and notify the provider?
A) Respiratory rate of 14 breaths/min and +2 deep tendon reflexes (DTRs)
B) Urine output of 40 mL/hr and flushing of the face
C) Respiratory rate of 10 breaths/min and absent deep tendon reflexes
D) Blood pressure of 150/90 mmHg and a mild headache
**Answer: C) Respiratory ra te of 10 breaths/min and absent deep tendon reflexes**
**Rationale:** These are signs of **Magnesium Sulfate toxicity**. The antidote is
**Calcium Gluconate** (10% solution), which must be kept at the bedside before
initiating the infusion. The cardinal signs of toxicity, in order of progression, are: Loss
of DTRs (earliest sign), Respiratory depression (<12 breaths/min), and Cardiac arrest.
Normal DTRs are +2. Flushing and a mild headache are common, expected side effects
of Mag Sulfate.
---
### Question 3
A patient at 30 weeks gestation arrives at the labor and delivery unit complaining of
sudden, painless, bright red vaginal bleeding. The fetal heart rate is 145 bpm and is
reassuring. What is the nurse's NEXT action?
A) Prepare the patient for an immediate vaginal delivery
B) Perform a sterile vaginal exam to determine cervical dilation
Exam 3: High-Risk Obstetrics & Newborn Care
Galen College of Nursing | Latest Verified A+ Guide
Question 1
A pregnant patient at 34 weeks gestation is admitted with a blood pressure of 160/110
mmHg, 3+ proteinuria, and severe edema. While the nurse is obtaining the history, the
patient begins to experience a tonic - clonic seizure. What is the nurse's PRIORITY
ac tion?
A) Administer oxytocin to induce labor
B) Protect the patient from injury, maintain a patent airway, and prepare to administer
Magnesium Sulfate
C) Immediately draw blood for a complete metabolic panel
D) Place the patient in a prone position to prev ent aspiration
**Answer: B) Protect the patient from injury, maintain a patent airway, and prepare to
administer Magnesium Sulfate**
**Rationale:** This patient has progressed from severe preeclampsia to **eclampsia**
(preeclampsia + seizures). The immediate priority during an active seizure is safety:
prevent injury (padded side rails, remove objects), protect the airway (turn to side if
possible, suction available), and administer the ordered IV loading dose of Magnesium
Sulfate to stop the seizure. Oxyt ocin is not a priority during an active seizure. Prone
position is contraindicated in pregnancy and impedes the airway.
, ---
### Question 2
A patient with severe preeclampsia is receiving an intravenous infusion of Magnesium
Sulfate. Which of the following assessment findings requires the nurse to STOP the
infusion IMMEDIATELY and notify the provider?
A) Respiratory rate of 14 breaths/min and +2 deep tendon reflexes (DTRs)
B) Urine output of 40 mL/hr and flushing of the face
C) Respiratory rate of 10 breaths/min and absent deep tendon reflexes
D) Blood pressure of 150/90 mmHg and a mild headache
**Answer: C) Respiratory ra te of 10 breaths/min and absent deep tendon reflexes**
**Rationale:** These are signs of **Magnesium Sulfate toxicity**. The antidote is
**Calcium Gluconate** (10% solution), which must be kept at the bedside before
initiating the infusion. The cardinal signs of toxicity, in order of progression, are: Loss
of DTRs (earliest sign), Respiratory depression (<12 breaths/min), and Cardiac arrest.
Normal DTRs are +2. Flushing and a mild headache are common, expected side effects
of Mag Sulfate.
---
### Question 3
A patient at 30 weeks gestation arrives at the labor and delivery unit complaining of
sudden, painless, bright red vaginal bleeding. The fetal heart rate is 145 bpm and is
reassuring. What is the nurse's NEXT action?
A) Prepare the patient for an immediate vaginal delivery
B) Perform a sterile vaginal exam to determine cervical dilation
