NUR 231 Maternal Nursing Exam 3 Comprehensive Practice 2026 UPDATE
1. A nurse is assessing a client who is at 32 weeks of gestation and reports painless vaginal
bleeding. Which of the following conditions should the nurse suspect?
A. Abruptio placentae
B. Placenta previa
C. Ectopic pregnancy
D. Molar pregnancy
Answer: B
Rationale: Placenta previa is characterized by painless, bright red vaginal bleeding during
the second or third trimester. Abruptio placentae usually presents with painful bleeding
and board-like abdominal rigidity.
2. Which of the following medications is administered to a newborn within 1 to 2 hours of
birth to prevent ophthalmia neonatorum?
A. Vitamin K (Phytonadione)
B. Erythromycin ophthalmic ointment
C. Hepatitis B vaccine
D. Nystatin
,Answer: B
Rationale: Erythromycin ophthalmic ointment is required by law in the US to prevent
blindness caused by Neisseria gonorrhoeae or Chlamydia trachomatis contracted during
birth.
3. A nurse is caring for a client in the first stage of labor and notes a fetal heart rate (FHR)
pattern of early decelerations. Which of the following actions should the nurse take?
A. Administer oxygen via non-rebreather mask
B. Turn the client to the left side-lying position
C. Prepare for an emergency cesarean birth
D. Document the finding and continue to monitor
Answer: D
Rationale: Early decelerations are caused by fetal head compression and are considered a
reassuring sign. They do not require intervention other than continued monitoring.
4. A client is receiving magnesium sulfate for preeclampsia. The nurse should identify which
of the following findings as an indication of magnesium toxicity?
A. Hyperreflexia (4+ deep tendon reflexes)
B. Urine output of 40 mL/hr
C. Respiratory rate of 10/min
D. Blood pressure of 150/90 mmHg
, Answer: C
Rationale: Signs of magnesium toxicity include a respiratory rate less than 12/min, loss of
deep tendon reflexes, and decreased urine output (less than 30 mL/hr).
5. A nurse is providing discharge teaching for a postpartum client who is breastfeeding.
Which of the following statements by the client indicates an understanding of the teaching?
A. I will wash my nipples with soap and water before each feeding.
B. I will apply a few drops of breast milk to my nipples after feeding.
C. I will feed my baby every 4 to 5 hours.
D. I will drink 1 liter of fluid per day to maintain milk supply.
Answer: B
Rationale: Applying breast milk to the nipples after feeding helps prevent cracking and
promotes healing. Soap should be avoided as it can be drying.
6. Which fetal heart rate pattern is associated with uteroplacental insufficiency?
A. Late decelerations
B. Early decelerations
C. Variable decelerations
D. Accelerations
Answer: A
1. A nurse is assessing a client who is at 32 weeks of gestation and reports painless vaginal
bleeding. Which of the following conditions should the nurse suspect?
A. Abruptio placentae
B. Placenta previa
C. Ectopic pregnancy
D. Molar pregnancy
Answer: B
Rationale: Placenta previa is characterized by painless, bright red vaginal bleeding during
the second or third trimester. Abruptio placentae usually presents with painful bleeding
and board-like abdominal rigidity.
2. Which of the following medications is administered to a newborn within 1 to 2 hours of
birth to prevent ophthalmia neonatorum?
A. Vitamin K (Phytonadione)
B. Erythromycin ophthalmic ointment
C. Hepatitis B vaccine
D. Nystatin
,Answer: B
Rationale: Erythromycin ophthalmic ointment is required by law in the US to prevent
blindness caused by Neisseria gonorrhoeae or Chlamydia trachomatis contracted during
birth.
3. A nurse is caring for a client in the first stage of labor and notes a fetal heart rate (FHR)
pattern of early decelerations. Which of the following actions should the nurse take?
A. Administer oxygen via non-rebreather mask
B. Turn the client to the left side-lying position
C. Prepare for an emergency cesarean birth
D. Document the finding and continue to monitor
Answer: D
Rationale: Early decelerations are caused by fetal head compression and are considered a
reassuring sign. They do not require intervention other than continued monitoring.
4. A client is receiving magnesium sulfate for preeclampsia. The nurse should identify which
of the following findings as an indication of magnesium toxicity?
A. Hyperreflexia (4+ deep tendon reflexes)
B. Urine output of 40 mL/hr
C. Respiratory rate of 10/min
D. Blood pressure of 150/90 mmHg
, Answer: C
Rationale: Signs of magnesium toxicity include a respiratory rate less than 12/min, loss of
deep tendon reflexes, and decreased urine output (less than 30 mL/hr).
5. A nurse is providing discharge teaching for a postpartum client who is breastfeeding.
Which of the following statements by the client indicates an understanding of the teaching?
A. I will wash my nipples with soap and water before each feeding.
B. I will apply a few drops of breast milk to my nipples after feeding.
C. I will feed my baby every 4 to 5 hours.
D. I will drink 1 liter of fluid per day to maintain milk supply.
Answer: B
Rationale: Applying breast milk to the nipples after feeding helps prevent cracking and
promotes healing. Soap should be avoided as it can be drying.
6. Which fetal heart rate pattern is associated with uteroplacental insufficiency?
A. Late decelerations
B. Early decelerations
C. Variable decelerations
D. Accelerations
Answer: A
