NUR 231 Maternal Nursing Exam 4 Practice Test 2026 UPDATE
1. A nurse is monitoring a client who is receiving magnesium sulfate for preeclampsia. Which
of the following findings should the nurse identify as a sign of magnesium toxicity?
A. Respiratory rate of 10/min
B. Hyperreflexia (DTRs 4+)
C. Increased urine output
D. Blood pressure 150/90 mmHg
Answer: A
Rationale: Magnesium sulfate toxicity causes central nervous system depression, leading
to decreased deep tendon reflexes, respiratory depression (less than 12/min), and
decreased urine output.
2. A client at 32 weeks of gestation presents with painless, bright red vaginal bleeding. Which
condition should the nurse suspect?
A. Abruptio placentae
B. Preterm labor
C. Placenta previa
D. Uterine rupture
,Answer: C
Rationale: Placenta previa is characterized by painless, bright red vaginal bleeding during
the second or third trimester. Abruptio placentae typically involves painful, dark red
bleeding.
3. A nurse is caring for a client in labor who has a fetal heart rate (FHR) tracing showing late
decelerations. Which of the following actions should the nurse take first?
A. Administer oxygen via non-rebreather mask
B. Increase the IV fluid rate
C. Notify the provider
D. Turn the client to the side-lying position
Answer: D
Rationale: Late decelerations indicate uteroplacental insufficiency. The priority action is to
improve placental perfusion, which is best achieved by repositioning the mother to her side
to relieve pressure on the vena cava.
4. Which medication is the antidote for magnesium sulfate toxicity?
A. Naloxone
B. Oxytocin
C. Terbutaline
D. Calcium gluconate
, Answer: D
Rationale: Calcium gluconate is the specific antidote to reverse the effects of magnesium
sulfate toxicity.
5. A postpartum nurse is assessing a client 2 hours after delivery. The fundus is boggy and
displaced to the right. Which action is appropriate?
A. Massage the fundus until firm
B. Notify the physician immediately
C. Assist the client to the bathroom to void
D. Increase the Pitocin infusion rate
Answer: C
Rationale: A displaced fundus to the right or left usually indicates a full bladder. Assisting
the client to void allows the uterus to return to the midline and contract effectively.
6. A nurse is performing an APGAR score on a newborn at 1 minute. Heart rate is 110/min,
respiratory effort is slow and irregular, muscle tone shows some flexion, the baby cries during
suctioning, and the body is pink with blue extremities. What is the score?
A. 6
B. 7
C. 8
D. 9
1. A nurse is monitoring a client who is receiving magnesium sulfate for preeclampsia. Which
of the following findings should the nurse identify as a sign of magnesium toxicity?
A. Respiratory rate of 10/min
B. Hyperreflexia (DTRs 4+)
C. Increased urine output
D. Blood pressure 150/90 mmHg
Answer: A
Rationale: Magnesium sulfate toxicity causes central nervous system depression, leading
to decreased deep tendon reflexes, respiratory depression (less than 12/min), and
decreased urine output.
2. A client at 32 weeks of gestation presents with painless, bright red vaginal bleeding. Which
condition should the nurse suspect?
A. Abruptio placentae
B. Preterm labor
C. Placenta previa
D. Uterine rupture
,Answer: C
Rationale: Placenta previa is characterized by painless, bright red vaginal bleeding during
the second or third trimester. Abruptio placentae typically involves painful, dark red
bleeding.
3. A nurse is caring for a client in labor who has a fetal heart rate (FHR) tracing showing late
decelerations. Which of the following actions should the nurse take first?
A. Administer oxygen via non-rebreather mask
B. Increase the IV fluid rate
C. Notify the provider
D. Turn the client to the side-lying position
Answer: D
Rationale: Late decelerations indicate uteroplacental insufficiency. The priority action is to
improve placental perfusion, which is best achieved by repositioning the mother to her side
to relieve pressure on the vena cava.
4. Which medication is the antidote for magnesium sulfate toxicity?
A. Naloxone
B. Oxytocin
C. Terbutaline
D. Calcium gluconate
, Answer: D
Rationale: Calcium gluconate is the specific antidote to reverse the effects of magnesium
sulfate toxicity.
5. A postpartum nurse is assessing a client 2 hours after delivery. The fundus is boggy and
displaced to the right. Which action is appropriate?
A. Massage the fundus until firm
B. Notify the physician immediately
C. Assist the client to the bathroom to void
D. Increase the Pitocin infusion rate
Answer: C
Rationale: A displaced fundus to the right or left usually indicates a full bladder. Assisting
the client to void allows the uterus to return to the midline and contract effectively.
6. A nurse is performing an APGAR score on a newborn at 1 minute. Heart rate is 110/min,
respiratory effort is slow and irregular, muscle tone shows some flexion, the baby cries during
suctioning, and the body is pink with blue extremities. What is the score?
A. 6
B. 7
C. 8
D. 9
