NUR 335 Exam 4: Maternal Health Theory & Application
V3 - Arizona College Updated and Latest Questions and
Correct Answers with Rationale
1. A nurse is caring for a client with preeclampsia who is receiving magnesium sulfate. Which finding is the
most critical to report to the healthcare provider?
A. Blood pressure of 150/96 mm Hg
B. Deep tendon reflexes of 2+ bilaterally
C. Urinary output of 40 mL per hour
D. Respiratory rate of 10 breaths per minute
Ans: D
Explanation: Magnesium sulfate toxicity leads to severe central nervous system depression. A
respiratory rate below 12 breaths per minute is a primary indicator of impending respiratory arrest. The
nurse must prioritize monitoring the airway and breathing in these high-risk clients. Immediate
discontinuation of the infusion and administration of calcium gluconate is required. This intervention
prevents life-threatening complications associated with hypermagnesemia.
2. A client at 34 weeks gestation presents with sudden-onset, sharp abdominal pain and vaginal bleeding.
The nurse notes a board-like, tender abdomen. What is the most likely diagnosis?
A. Abruptio placentae
B. Placenta previa
C. Uterine rupture
D. Cervical insufficiency
Ans: A
,Explanation: Abruptio placentae is characterized by premature separation of the placenta from the
uterine wall. Classic symptoms include painful vaginal bleeding and a rigid, board-like abdomen. This
condition differs from placenta previa, which is usually painless. Immediate nursing care focuses on
monitoring maternal hemodynamic stability and fetal heart rate. Prompt recognition is essential to
prevent maternal hemorrhage and fetal hypoxia.
3. During the active phase of labor, a nurse observes late decelerations on the fetal monitor strip. What is
the priority nursing action?
A. Increase the rate of the oxytocin infusion
B. Perform a sterile vaginal examination
C. Reposition the client to a side-lying position
D. Instruct the client to use patterned breathing
Ans: C
Explanation: Late decelerations are indicative of uteroplacental insufficiency and fetal distress.
Repositioning the mother to her side enhances uterine perfusion and fetal oxygenation. Oxytocin should
be discontinued immediately if the fetus is showing signs of intolerance. Providing supplemental oxygen
and increasing IV fluids are also critical supporting measures. These actions aim to reverse fetal hypoxia
before permanent damage occurs.
4. A postpartum client who is 2 hours post-delivery has a saturated perineal pad and a soft, boggy fundus
located above the umbilicus. What is the initial nursing intervention?
A. Administer methylergonovine as ordered
B. Notify the healthcare provider immediately
C. Perform fundal massage until firm
, D. Assist the client to the bathroom to void
Ans: C
Explanation: A boggy uterus is the most common cause of postpartum hemorrhage due to uterine atony.
Massage stimulates uterine contractions to compress blood vessels and stop bleeding. If the fundus is
displaced, the bladder should be emptied after stabilization. Medications like oxytocin or
methylergonovine are utilized if massage is ineffective. Rapid intervention is vital to prevent
hypovolemic shock in the postpartum period.
5. Which lab finding is characteristic of HELLP syndrome in a client with severe preeclampsia?
A. Increased hemoglobin levels
B. Elevated serum creatinine
C. Low platelet count below 100,000/mm3
D. Decreased liver enzymes
Ans: C
Explanation: HELLP syndrome stands for hemolysis, elevated liver enzymes, and low platelets.
Thrombocytopenia is a hallmark sign caused by platelet adhesion to damaged vascular endothelium.
Hemolysis is typically identified by an abnormal peripheral blood smear. Elevated liver enzymes reflect
hepatic tissue damage and swelling. Management involves stabilization and often delivery to prevent
multi-organ failure.
6. A nurse is preparing to administer Rho(D) immune globulin to a postpartum client. Which client profile
requires this medication?
A. Rh-positive mother with an Rh-negative newborn
B. Rh-negative mother with an Rh-negative newborn
V3 - Arizona College Updated and Latest Questions and
Correct Answers with Rationale
1. A nurse is caring for a client with preeclampsia who is receiving magnesium sulfate. Which finding is the
most critical to report to the healthcare provider?
A. Blood pressure of 150/96 mm Hg
B. Deep tendon reflexes of 2+ bilaterally
C. Urinary output of 40 mL per hour
D. Respiratory rate of 10 breaths per minute
Ans: D
Explanation: Magnesium sulfate toxicity leads to severe central nervous system depression. A
respiratory rate below 12 breaths per minute is a primary indicator of impending respiratory arrest. The
nurse must prioritize monitoring the airway and breathing in these high-risk clients. Immediate
discontinuation of the infusion and administration of calcium gluconate is required. This intervention
prevents life-threatening complications associated with hypermagnesemia.
2. A client at 34 weeks gestation presents with sudden-onset, sharp abdominal pain and vaginal bleeding.
The nurse notes a board-like, tender abdomen. What is the most likely diagnosis?
A. Abruptio placentae
B. Placenta previa
C. Uterine rupture
D. Cervical insufficiency
Ans: A
,Explanation: Abruptio placentae is characterized by premature separation of the placenta from the
uterine wall. Classic symptoms include painful vaginal bleeding and a rigid, board-like abdomen. This
condition differs from placenta previa, which is usually painless. Immediate nursing care focuses on
monitoring maternal hemodynamic stability and fetal heart rate. Prompt recognition is essential to
prevent maternal hemorrhage and fetal hypoxia.
3. During the active phase of labor, a nurse observes late decelerations on the fetal monitor strip. What is
the priority nursing action?
A. Increase the rate of the oxytocin infusion
B. Perform a sterile vaginal examination
C. Reposition the client to a side-lying position
D. Instruct the client to use patterned breathing
Ans: C
Explanation: Late decelerations are indicative of uteroplacental insufficiency and fetal distress.
Repositioning the mother to her side enhances uterine perfusion and fetal oxygenation. Oxytocin should
be discontinued immediately if the fetus is showing signs of intolerance. Providing supplemental oxygen
and increasing IV fluids are also critical supporting measures. These actions aim to reverse fetal hypoxia
before permanent damage occurs.
4. A postpartum client who is 2 hours post-delivery has a saturated perineal pad and a soft, boggy fundus
located above the umbilicus. What is the initial nursing intervention?
A. Administer methylergonovine as ordered
B. Notify the healthcare provider immediately
C. Perform fundal massage until firm
, D. Assist the client to the bathroom to void
Ans: C
Explanation: A boggy uterus is the most common cause of postpartum hemorrhage due to uterine atony.
Massage stimulates uterine contractions to compress blood vessels and stop bleeding. If the fundus is
displaced, the bladder should be emptied after stabilization. Medications like oxytocin or
methylergonovine are utilized if massage is ineffective. Rapid intervention is vital to prevent
hypovolemic shock in the postpartum period.
5. Which lab finding is characteristic of HELLP syndrome in a client with severe preeclampsia?
A. Increased hemoglobin levels
B. Elevated serum creatinine
C. Low platelet count below 100,000/mm3
D. Decreased liver enzymes
Ans: C
Explanation: HELLP syndrome stands for hemolysis, elevated liver enzymes, and low platelets.
Thrombocytopenia is a hallmark sign caused by platelet adhesion to damaged vascular endothelium.
Hemolysis is typically identified by an abnormal peripheral blood smear. Elevated liver enzymes reflect
hepatic tissue damage and swelling. Management involves stabilization and often delivery to prevent
multi-organ failure.
6. A nurse is preparing to administer Rho(D) immune globulin to a postpartum client. Which client profile
requires this medication?
A. Rh-positive mother with an Rh-negative newborn
B. Rh-negative mother with an Rh-negative newborn
