NUR 254 Exam 3 Practice Questions with Correct Answers and
Explanations in Italics Maternal & Pediatric Nursing - Galen
College of Nursing - 127 Questions
Section 1: Antepartum Care and Complications (Questions 1-13)
1 A client at 28 weeks gestation with a history of chronic hypertension presents with a blood pressure of 160/100
mm Hg and proteinuria of 300 mg in a 24-hour urine collection. Which finding is most indicative of severe
preeclampsia rather than gestational hypertension?
A) Blood pressure 160/100 mm Hg
B) Proteinuria 300 mg/24h
C) Platelet count of 80,000/mm³
D) Serum creatinine 0.9 mg/dL
Answer: C
Rationale: Severe preeclampsia is characterized by thrombocytopenia (platelets <100,000/mm³), while proteinuria
300 mg/24h and BP 140/90 are criteria for preeclampsia but not necessarily severe. Creatinine >1.1 mg/dL
indicates renal dysfunction, but 0.9 mg/dL is normal.
2 A client with gestational diabetes mellitus (GDM) at 32 weeks gestation has a fasting plasma glucose of 105
mg/dL and a 2-hour postprandial glucose of 155 mg/dL despite dietary modifications. Which intervention is
most appropriate?
A) Increase complex carbohydrates in diet
B) Initiate insulin therapy
C) Start oral metformin
D) Schedule induction at 36 weeks
Answer: B
Rationale: When dietary management fails to maintain fasting glucose <95 mg/dL and 2-hour postprandial <120
mg/dL, insulin is first-line pharmacotherapy in GDM. Metformin is not first-line and may cross placenta. Induction
is not indicated at 32 weeks.
3 A client at 34 weeks gestation presents with painless vaginal bleeding. Ultrasound reveals a placenta previa.
Which nursing action is contraindicated?
A) Assess fetal heart rate via external monitor
B) Perform a sterile vaginal exam
C) Obtain IV access and type and crossmatch
D) Administer betamethasone
Answer: B
Rationale: Vaginal examination is contraindicated in suspected placenta previa as it can disrupt the placenta and
cause catastrophic hemorrhage. External fetal monitoring, IV access, and betamethasone for fetal lung maturity are
appropriate.
4 A client with preterm premature rupture of membranes (PPROM) at 30 weeks gestation is not in labor. Which
finding most strongly indicates chorioamnionitis?
A) Maternal white blood cell count of 14,000/mm³
B) Fetal tachycardia of 170 bpm
,C) Maternal temperature of 37.8°C (100.0°F)
D) Amniotic fluid glucose of 20 mg/dL
Answer: B
Rationale: F e t a l t a c h y c a r d i a ("e 1 6 0 b p m ) i s a c l a s s
labor or infection; a single temperature >38°C is more specific. Low amniotic fluid glucose (<10 mg/dL) is
suggestive, but 20 mg/dL is borderline.
5 A client at 26 weeks gestation is diagnosed with acute fatty liver of pregnancy (AFLP). Which laboratory
finding is most consistent with this condition?
A) Elevated serum aminotransferases (AST/ALT) with normal bilirubin
B) Elevated bilirubin with mild transaminase elevation
C) Markedly elevated alkaline phosphatase with normal transaminases
D) Elevated creatinine with normal liver enzymes
Answer: B
Rationale: AFLP typically presents with elevated bilirubin (jaundice) and mild to moderate transaminase elevation.
Severe transaminase elevation is more typical of viral hepatitis. Alkaline phosphatase normally rises in pregnancy.
Renal impairment may occur but is not diagnostic.
6 A client with a history of recurrent pregnancy loss undergoes evaluation for antiphospholipid syndrome (APS).
Which laboratory finding is diagnostic?
A) Positive anti-nuclear antibody (ANA) titer 1:160
B) Elevated factor V Leiden mutation
C) Positive lupus anticoagulant on two occasions 12 weeks apart
D) Elevated homocysteine level 15 µmol/L
Answer: C
Rationale: D i a g n o s i s o f A P S r e q u i r e s p e r s i s t e n t ("e
anti-2 glycoprotein I antibodies. ANA is nonspecific. Factor V Leiden and hyperhomocysteinemia are
thrombophilias but not diagnostic for APS.
7 A client at 18 weeks gestation undergoes a quad screen. Results show elevated alpha-fetoprotein (AFP). Which
condition is most likely?
A) Down syndrome
B) Neural tube defect
C) Trisomy 18
D) Gestational trophoblastic disease
Answer: B
Rationale: Elevated maternal serum AFP is associated with open neural tube defects. Low AFP is associated with
Down syndrome and trisomy 18. Gestational trophoblastic disease may cause very high hCG, not typically elevated
AFP.
8 A client with a triplet pregnancy at 28 weeks gestation develops preterm labor. Which tocolytic agent is most
appropriate?
A) Terbutaline
B) Nifedipine
C) Indomethacin
D) Magnesium sulfate
,Answer: D
Rationale: Magnesium sulfate is preferred for tocolysis in multiple gestations due to lower risk of maternal side
effects compared to terbutaline (cardiac) and nifedipine (hypotension). Indomethacin is avoided after 32 weeks due
to oligohydramnios and ductal closure.
9 A client at 38 weeks gestation with severe preeclampsia is receiving intravenous magnesium sulfate. Which
finding indicates magnesium toxicity?
A) Respiratory rate 14 breaths/min
B) Deep tendon reflexes 2+
C) Urine output 40 mL/hour
D) Serum magnesium level 8.5 mEq/L
Answer: D
Rationale: Therapeutic magnesium level is 4-7 mEq/L; toxicity typically occurs at >7 mEq/L. Loss of deep tendon
reflexes occurs at 8-10 mEq/L, respiratory depression at >12 mEq/L. Urine output >30 mL/hr is adequate. RR 14 is
normal.
10 A client at 20 weeks gestation is diagnosed with an incompetent cervix. Which intervention is most
appropriate?
A) Bed rest with pelvic rest
B) Transvaginal cervical cerclage
C) Progesterone supplementation
D) Induction of labor at 34 weeks
Answer: B
Rationale: For a singleton pregnancy with prior second-trimester loss due to cervical insufficiency, cerclage is
recommended at 12-14 weeks. Bed rest and progesterone are not definitive treatments. Induction is not indicated at
20 weeks.
11 A pregnant individual at 28 weeks gestation presents with a blood pressure of 158/102 mmHg and 3+
proteinuria on dipstick. Urgent evaluation reveals a platelet count of 90,000/µL, elevated liver enzymes (AST
120 U/L, ALT 150 U/L), and right upper quadrant tenderness. Which of the following pathophysiological
mechanisms best explains the concurrent hepatic involvement in this condition?
A) Hepatic ischemia due to vasospasm of the hepatic artery secondary to systemic hypertension
B) Periportal hemorrhagic necrosis and fibrin deposition in hepatic sinusoids from microvascular thrombosis
C) Cholestatic injury from elevated estrogen and progesterone levels in pregnancy
D) Autoimmune-mediated hepatocyte destruction triggered by placental trophoblast antigens
Answer: B
Rationale: This presentation is consistent with severe preeclampsia with features of HELLP syndrome. The hepatic
involvement is due to microvascular thrombosis, leading to periportal necrosis and fibrin deposition, not simply
ischemia or cholestasis. Autoimmune mechanisms are not primary in preeclampsia.
12 A patient at 16 weeks gestation with a history of two prior unexplained second-trimester losses now presents
with a short cervical length of 22 mm on transvaginal ultrasound. There are no signs of infection or bleeding.
Which of the following interventions is most appropriate for preventing preterm birth in this case?
A) Prophylactic cervical cerclage placement immediately
B) Vaginal progesterone supplementation and serial cervical length monitoring
C) Intramuscular 17-alpha-hydroxyprogesterone caproate weekly
D) Bed rest and pelvic rest with no pharmacological intervention
, Answer: B
Rationale: F o r a p a t i e n t w i t h a s h o r t c e r v i x ("d 2 5
progesterone is recommended. Cerclage is typically reserved for those with a history of cervical insufficiency or
short cervix <20 mm, especially if prior preterm birth. 17-OHPC is used for prevention of recurrent preterm birth
but not specifically for short cervix. Bed rest is not evidence-based.
13 A pregnant individual at 34 weeks gestation with poorly controlled type 1 diabetes mellitus is admitted with
polyhydramnios and suspected fetal macrosomia. Biophysical profile score is 6/10 (points lost for amniotic
fluid volume and fetal breathing movements). Which of the following fetal complications is most directly
attributed to maternal hyperglycemia, and what is the underlying mechanism?
A) Neonatal hypoglycemia due to fetal hyperinsulinemia following maternal glucose elevation
B) Neonatal respiratory distress syndrome from delayed pulmonary surfactant maturation
C) Fetal congenital anomalies due to first-trimester hyperglycemia
D) Fetal growth restriction due to uteroplacental insufficiency from vasculopathy
Answer: A
Rationale: Maternal hyperglycemia leads to fetal hyperglycemia, stimulating fetal pancreatic beta cells to produce
excess insulin. After birth, the continued high insulin levels cause hypoglycemia. This is a direct consequence of
poor glycemic control in the third trimester. Respiratory distress is more associated with prematurity, not directly
with hyperglycemia. Congenital anomalies result from first-trimester exposure, not third trimester. Macrosomia,
not growth restriction, is typical.
Section 2: Intrapartum Care and Complications (Questions 14-26)
14 During a prolonged second stage of labor with the fetus in occiput posterior position, the nurse observes a
sudden increase in uterine resting tone between contractions accompanied by a rising baseline fetal heart rate
and minimal variability. Which physiological mechanism most likely underlies these findings?
A) Uterine atony leading to placental hypoperfusion
B) Tetanic contraction secondary to excessive oxytocin stimulation
C) Placental abruption with concealed hemorrhage
D) Fetal head compression causing vagal response
Answer: C
Rationale: Placental abruption can present with increased uterine resting tone (hypertonus) and a rising baseline
FHR with minimal variability due to fetal hypoxia. Uterine atony (A) presents with relaxation, not hypertonus.
Tetanic contraction (B) would show a prolonged contraction, not just increased resting tone. Fetal head
compression (D) typically causes variable decelerations, not a rising baseline with minimal variability.
15 A nulliparous patient with a history of cervical insufficiency undergoes emergency cerclage placement at 22
weeks gestation. She presents at 38 weeks with regular contractions and cervical dilation of 4 cm. The cerclage
is removed, but the patient develops a fever of 38.9°C and uterine tenderness. Which intrapartum complication
is most likely to be exacerbated by the presence of the cerclage?
A) Uterine rupture
B) Chorioamnionitis
C) Amniotic fluid embolism
D) Placenta accreta
Answer: B
Rationale: Cerclage, especially when placed emergently, increases the risk of ascending infection and
chorioamnionitis due to foreign material and potential cervical trauma. Uterine rupture (A) is more associated with
Explanations in Italics Maternal & Pediatric Nursing - Galen
College of Nursing - 127 Questions
Section 1: Antepartum Care and Complications (Questions 1-13)
1 A client at 28 weeks gestation with a history of chronic hypertension presents with a blood pressure of 160/100
mm Hg and proteinuria of 300 mg in a 24-hour urine collection. Which finding is most indicative of severe
preeclampsia rather than gestational hypertension?
A) Blood pressure 160/100 mm Hg
B) Proteinuria 300 mg/24h
C) Platelet count of 80,000/mm³
D) Serum creatinine 0.9 mg/dL
Answer: C
Rationale: Severe preeclampsia is characterized by thrombocytopenia (platelets <100,000/mm³), while proteinuria
300 mg/24h and BP 140/90 are criteria for preeclampsia but not necessarily severe. Creatinine >1.1 mg/dL
indicates renal dysfunction, but 0.9 mg/dL is normal.
2 A client with gestational diabetes mellitus (GDM) at 32 weeks gestation has a fasting plasma glucose of 105
mg/dL and a 2-hour postprandial glucose of 155 mg/dL despite dietary modifications. Which intervention is
most appropriate?
A) Increase complex carbohydrates in diet
B) Initiate insulin therapy
C) Start oral metformin
D) Schedule induction at 36 weeks
Answer: B
Rationale: When dietary management fails to maintain fasting glucose <95 mg/dL and 2-hour postprandial <120
mg/dL, insulin is first-line pharmacotherapy in GDM. Metformin is not first-line and may cross placenta. Induction
is not indicated at 32 weeks.
3 A client at 34 weeks gestation presents with painless vaginal bleeding. Ultrasound reveals a placenta previa.
Which nursing action is contraindicated?
A) Assess fetal heart rate via external monitor
B) Perform a sterile vaginal exam
C) Obtain IV access and type and crossmatch
D) Administer betamethasone
Answer: B
Rationale: Vaginal examination is contraindicated in suspected placenta previa as it can disrupt the placenta and
cause catastrophic hemorrhage. External fetal monitoring, IV access, and betamethasone for fetal lung maturity are
appropriate.
4 A client with preterm premature rupture of membranes (PPROM) at 30 weeks gestation is not in labor. Which
finding most strongly indicates chorioamnionitis?
A) Maternal white blood cell count of 14,000/mm³
B) Fetal tachycardia of 170 bpm
,C) Maternal temperature of 37.8°C (100.0°F)
D) Amniotic fluid glucose of 20 mg/dL
Answer: B
Rationale: F e t a l t a c h y c a r d i a ("e 1 6 0 b p m ) i s a c l a s s
labor or infection; a single temperature >38°C is more specific. Low amniotic fluid glucose (<10 mg/dL) is
suggestive, but 20 mg/dL is borderline.
5 A client at 26 weeks gestation is diagnosed with acute fatty liver of pregnancy (AFLP). Which laboratory
finding is most consistent with this condition?
A) Elevated serum aminotransferases (AST/ALT) with normal bilirubin
B) Elevated bilirubin with mild transaminase elevation
C) Markedly elevated alkaline phosphatase with normal transaminases
D) Elevated creatinine with normal liver enzymes
Answer: B
Rationale: AFLP typically presents with elevated bilirubin (jaundice) and mild to moderate transaminase elevation.
Severe transaminase elevation is more typical of viral hepatitis. Alkaline phosphatase normally rises in pregnancy.
Renal impairment may occur but is not diagnostic.
6 A client with a history of recurrent pregnancy loss undergoes evaluation for antiphospholipid syndrome (APS).
Which laboratory finding is diagnostic?
A) Positive anti-nuclear antibody (ANA) titer 1:160
B) Elevated factor V Leiden mutation
C) Positive lupus anticoagulant on two occasions 12 weeks apart
D) Elevated homocysteine level 15 µmol/L
Answer: C
Rationale: D i a g n o s i s o f A P S r e q u i r e s p e r s i s t e n t ("e
anti-2 glycoprotein I antibodies. ANA is nonspecific. Factor V Leiden and hyperhomocysteinemia are
thrombophilias but not diagnostic for APS.
7 A client at 18 weeks gestation undergoes a quad screen. Results show elevated alpha-fetoprotein (AFP). Which
condition is most likely?
A) Down syndrome
B) Neural tube defect
C) Trisomy 18
D) Gestational trophoblastic disease
Answer: B
Rationale: Elevated maternal serum AFP is associated with open neural tube defects. Low AFP is associated with
Down syndrome and trisomy 18. Gestational trophoblastic disease may cause very high hCG, not typically elevated
AFP.
8 A client with a triplet pregnancy at 28 weeks gestation develops preterm labor. Which tocolytic agent is most
appropriate?
A) Terbutaline
B) Nifedipine
C) Indomethacin
D) Magnesium sulfate
,Answer: D
Rationale: Magnesium sulfate is preferred for tocolysis in multiple gestations due to lower risk of maternal side
effects compared to terbutaline (cardiac) and nifedipine (hypotension). Indomethacin is avoided after 32 weeks due
to oligohydramnios and ductal closure.
9 A client at 38 weeks gestation with severe preeclampsia is receiving intravenous magnesium sulfate. Which
finding indicates magnesium toxicity?
A) Respiratory rate 14 breaths/min
B) Deep tendon reflexes 2+
C) Urine output 40 mL/hour
D) Serum magnesium level 8.5 mEq/L
Answer: D
Rationale: Therapeutic magnesium level is 4-7 mEq/L; toxicity typically occurs at >7 mEq/L. Loss of deep tendon
reflexes occurs at 8-10 mEq/L, respiratory depression at >12 mEq/L. Urine output >30 mL/hr is adequate. RR 14 is
normal.
10 A client at 20 weeks gestation is diagnosed with an incompetent cervix. Which intervention is most
appropriate?
A) Bed rest with pelvic rest
B) Transvaginal cervical cerclage
C) Progesterone supplementation
D) Induction of labor at 34 weeks
Answer: B
Rationale: For a singleton pregnancy with prior second-trimester loss due to cervical insufficiency, cerclage is
recommended at 12-14 weeks. Bed rest and progesterone are not definitive treatments. Induction is not indicated at
20 weeks.
11 A pregnant individual at 28 weeks gestation presents with a blood pressure of 158/102 mmHg and 3+
proteinuria on dipstick. Urgent evaluation reveals a platelet count of 90,000/µL, elevated liver enzymes (AST
120 U/L, ALT 150 U/L), and right upper quadrant tenderness. Which of the following pathophysiological
mechanisms best explains the concurrent hepatic involvement in this condition?
A) Hepatic ischemia due to vasospasm of the hepatic artery secondary to systemic hypertension
B) Periportal hemorrhagic necrosis and fibrin deposition in hepatic sinusoids from microvascular thrombosis
C) Cholestatic injury from elevated estrogen and progesterone levels in pregnancy
D) Autoimmune-mediated hepatocyte destruction triggered by placental trophoblast antigens
Answer: B
Rationale: This presentation is consistent with severe preeclampsia with features of HELLP syndrome. The hepatic
involvement is due to microvascular thrombosis, leading to periportal necrosis and fibrin deposition, not simply
ischemia or cholestasis. Autoimmune mechanisms are not primary in preeclampsia.
12 A patient at 16 weeks gestation with a history of two prior unexplained second-trimester losses now presents
with a short cervical length of 22 mm on transvaginal ultrasound. There are no signs of infection or bleeding.
Which of the following interventions is most appropriate for preventing preterm birth in this case?
A) Prophylactic cervical cerclage placement immediately
B) Vaginal progesterone supplementation and serial cervical length monitoring
C) Intramuscular 17-alpha-hydroxyprogesterone caproate weekly
D) Bed rest and pelvic rest with no pharmacological intervention
, Answer: B
Rationale: F o r a p a t i e n t w i t h a s h o r t c e r v i x ("d 2 5
progesterone is recommended. Cerclage is typically reserved for those with a history of cervical insufficiency or
short cervix <20 mm, especially if prior preterm birth. 17-OHPC is used for prevention of recurrent preterm birth
but not specifically for short cervix. Bed rest is not evidence-based.
13 A pregnant individual at 34 weeks gestation with poorly controlled type 1 diabetes mellitus is admitted with
polyhydramnios and suspected fetal macrosomia. Biophysical profile score is 6/10 (points lost for amniotic
fluid volume and fetal breathing movements). Which of the following fetal complications is most directly
attributed to maternal hyperglycemia, and what is the underlying mechanism?
A) Neonatal hypoglycemia due to fetal hyperinsulinemia following maternal glucose elevation
B) Neonatal respiratory distress syndrome from delayed pulmonary surfactant maturation
C) Fetal congenital anomalies due to first-trimester hyperglycemia
D) Fetal growth restriction due to uteroplacental insufficiency from vasculopathy
Answer: A
Rationale: Maternal hyperglycemia leads to fetal hyperglycemia, stimulating fetal pancreatic beta cells to produce
excess insulin. After birth, the continued high insulin levels cause hypoglycemia. This is a direct consequence of
poor glycemic control in the third trimester. Respiratory distress is more associated with prematurity, not directly
with hyperglycemia. Congenital anomalies result from first-trimester exposure, not third trimester. Macrosomia,
not growth restriction, is typical.
Section 2: Intrapartum Care and Complications (Questions 14-26)
14 During a prolonged second stage of labor with the fetus in occiput posterior position, the nurse observes a
sudden increase in uterine resting tone between contractions accompanied by a rising baseline fetal heart rate
and minimal variability. Which physiological mechanism most likely underlies these findings?
A) Uterine atony leading to placental hypoperfusion
B) Tetanic contraction secondary to excessive oxytocin stimulation
C) Placental abruption with concealed hemorrhage
D) Fetal head compression causing vagal response
Answer: C
Rationale: Placental abruption can present with increased uterine resting tone (hypertonus) and a rising baseline
FHR with minimal variability due to fetal hypoxia. Uterine atony (A) presents with relaxation, not hypertonus.
Tetanic contraction (B) would show a prolonged contraction, not just increased resting tone. Fetal head
compression (D) typically causes variable decelerations, not a rising baseline with minimal variability.
15 A nulliparous patient with a history of cervical insufficiency undergoes emergency cerclage placement at 22
weeks gestation. She presents at 38 weeks with regular contractions and cervical dilation of 4 cm. The cerclage
is removed, but the patient develops a fever of 38.9°C and uterine tenderness. Which intrapartum complication
is most likely to be exacerbated by the presence of the cerclage?
A) Uterine rupture
B) Chorioamnionitis
C) Amniotic fluid embolism
D) Placenta accreta
Answer: B
Rationale: Cerclage, especially when placed emergently, increases the risk of ascending infection and
chorioamnionitis due to foreign material and potential cervical trauma. Uterine rupture (A) is more associated with
