NUR 335 Exam 4: Maternal Health Theory & Application
V2 - Arizona College Updated and Latest Questions and
Correct Answers with Rationale
1. A nurse is monitoring a client in active labor and notes late decelerations on the fetal heart rate monitor.
Which of the following is the priority nursing action?
A. Reposition the client to a lateral side-lying position.
B. Apply oxygen at 8 to 10 liters via a non-rebreather mask.
C. Increase the rate of the intravenous fluid bolus.
D. Perform a sterile vaginal exam to check for cord prolapse.
Ans: A
Explanation: Late decelerations are caused by uteroplacental insufficiency and indicate that the fetus is
not receiving adequate oxygen. The first action the nurse should take is to reposition the client to the side
to enhance placental perfusion. Following repositioning, the nurse should increase fluids and provide
oxygen to further improve fetal status. It is also essential to discontinue any oxytocin that may be infusing
to reduce uterine stress. Immediate assessment and intervention are necessary to prevent fetal hypoxia
and metabolic acidosis.
2. A client at 34 weeks of gestation is receiving magnesium sulfate for preeclampsia. Which finding should
the nurse report to the provider immediately?
A. Fetal heart rate of 140 beats per minute.
B. Deep tendon reflexes of 2+.
C. Urine output of 20 mL per hour.
D. Respiratory rate of 16 breaths per minute.
,Ans: C
Explanation: Magnesium sulfate is excreted by the kidneys, so decreased urine output can lead to toxic
levels of the medication. A urine output of less than 30 mL per hour is a significant finding that requires
immediate notification of the provider. The nurse must also monitor for signs of toxicity such as loss of
deep tendon reflexes and respiratory depression. Normal deep tendon reflexes and a respiratory rate of
16 are expected findings during therapy. Ensuring renal clearance is vital to maintaining a safe
therapeutic range for the patient.
3. The nurse is caring for a client who is 2 hours postpartum and identifies that the uterus is boggy and
displaced to the right. What is the nurse’s first action?
A. Administer oxytocin as ordered by the physician.
B. Assist the client to the bathroom to void.
C. Massage the fundus until it becomes firm.
D. Notify the provider of the abnormal finding.
Ans: B
Explanation: A boggy uterus that is displaced to the right is a classic sign of bladder distention. A full
bladder prevents the uterus from contracting effectively, which increases the risk of postpartum
hemorrhage. Assisting the client to void should be the priority to allow the uterus to return to the midline
and contract. If the uterus remains boggy after voiding, then fundal massage and medications may be
required. Prompt intervention for bladder distention is a key component of postpartum safety.
4. A newborn has a heart rate of 110 bpm, a slow/weak cry, some flexion of extremities, is grimacing in
response to a catheter, and has a pink body with blue extremities. What is the APGAR score?
A. 5
, B. 6
C. 7
D. 8
Ans: B
Explanation: The APGAR score is calculated based on five categories to assess the newborn’s transition
to extrauterine life. This infant receives 2 points for a heart rate over 100 and 1 point for a slow cry. The
infant earns 1 point for some flexion and 1 point for grimacing during stimulation. Acrocyanosis, or a
pink body with blue extremities, results in 1 point for appearance. Adding these values together gives a
total APGAR score of 6 for this newborn.
5. A nurse is teaching a client about a 1-hour glucose tolerance test (GTT) for gestational diabetes. Which
instruction is correct?
A. The client must fast for 12 hours prior to the blood draw.
B. The test is performed between 14 and 18 weeks of gestation.
C. The client will drink a 50-gram glucose solution.
D. A blood glucose level of 110 mg/dL is considered a positive screen.
Ans: C
Explanation: The 1-hour glucose tolerance test is a screening tool used to identify risk for gestational
diabetes. Unlike the 3-hour test, the 1-hour GTT does not require the patient to be fasting beforehand.
The patient consumes a 50-gram glucose load, and blood is drawn exactly one hour later. This screening
is typically performed between 24 and 28 weeks of gestation for most pregnant women. A result higher
than 130 to 140 mg/dL usually necessitates further diagnostic testing with a 3-hour GTT.
V2 - Arizona College Updated and Latest Questions and
Correct Answers with Rationale
1. A nurse is monitoring a client in active labor and notes late decelerations on the fetal heart rate monitor.
Which of the following is the priority nursing action?
A. Reposition the client to a lateral side-lying position.
B. Apply oxygen at 8 to 10 liters via a non-rebreather mask.
C. Increase the rate of the intravenous fluid bolus.
D. Perform a sterile vaginal exam to check for cord prolapse.
Ans: A
Explanation: Late decelerations are caused by uteroplacental insufficiency and indicate that the fetus is
not receiving adequate oxygen. The first action the nurse should take is to reposition the client to the side
to enhance placental perfusion. Following repositioning, the nurse should increase fluids and provide
oxygen to further improve fetal status. It is also essential to discontinue any oxytocin that may be infusing
to reduce uterine stress. Immediate assessment and intervention are necessary to prevent fetal hypoxia
and metabolic acidosis.
2. A client at 34 weeks of gestation is receiving magnesium sulfate for preeclampsia. Which finding should
the nurse report to the provider immediately?
A. Fetal heart rate of 140 beats per minute.
B. Deep tendon reflexes of 2+.
C. Urine output of 20 mL per hour.
D. Respiratory rate of 16 breaths per minute.
,Ans: C
Explanation: Magnesium sulfate is excreted by the kidneys, so decreased urine output can lead to toxic
levels of the medication. A urine output of less than 30 mL per hour is a significant finding that requires
immediate notification of the provider. The nurse must also monitor for signs of toxicity such as loss of
deep tendon reflexes and respiratory depression. Normal deep tendon reflexes and a respiratory rate of
16 are expected findings during therapy. Ensuring renal clearance is vital to maintaining a safe
therapeutic range for the patient.
3. The nurse is caring for a client who is 2 hours postpartum and identifies that the uterus is boggy and
displaced to the right. What is the nurse’s first action?
A. Administer oxytocin as ordered by the physician.
B. Assist the client to the bathroom to void.
C. Massage the fundus until it becomes firm.
D. Notify the provider of the abnormal finding.
Ans: B
Explanation: A boggy uterus that is displaced to the right is a classic sign of bladder distention. A full
bladder prevents the uterus from contracting effectively, which increases the risk of postpartum
hemorrhage. Assisting the client to void should be the priority to allow the uterus to return to the midline
and contract. If the uterus remains boggy after voiding, then fundal massage and medications may be
required. Prompt intervention for bladder distention is a key component of postpartum safety.
4. A newborn has a heart rate of 110 bpm, a slow/weak cry, some flexion of extremities, is grimacing in
response to a catheter, and has a pink body with blue extremities. What is the APGAR score?
A. 5
, B. 6
C. 7
D. 8
Ans: B
Explanation: The APGAR score is calculated based on five categories to assess the newborn’s transition
to extrauterine life. This infant receives 2 points for a heart rate over 100 and 1 point for a slow cry. The
infant earns 1 point for some flexion and 1 point for grimacing during stimulation. Acrocyanosis, or a
pink body with blue extremities, results in 1 point for appearance. Adding these values together gives a
total APGAR score of 6 for this newborn.
5. A nurse is teaching a client about a 1-hour glucose tolerance test (GTT) for gestational diabetes. Which
instruction is correct?
A. The client must fast for 12 hours prior to the blood draw.
B. The test is performed between 14 and 18 weeks of gestation.
C. The client will drink a 50-gram glucose solution.
D. A blood glucose level of 110 mg/dL is considered a positive screen.
Ans: C
Explanation: The 1-hour glucose tolerance test is a screening tool used to identify risk for gestational
diabetes. Unlike the 3-hour test, the 1-hour GTT does not require the patient to be fasting beforehand.
The patient consumes a 50-gram glucose load, and blood is drawn exactly one hour later. This screening
is typically performed between 24 and 28 weeks of gestation for most pregnant women. A result higher
than 130 to 140 mg/dL usually necessitates further diagnostic testing with a 3-hour GTT.
