NURS 203 | NURS 203 Maternity Exam 3 Version 3 |
Questions with Correct Answers and Expert
Explanation for Each Question | Saint Paul’s School
of Nursing
1. A client in the transition phase of labor is experiencing lightheadedness and tingling
in her fingers while using patterned-paced breathing. Which action should the nurse
take first?
A. Instruct the client to breathe into her cupped hands.
B. Administer oxygen via a non-rebreather mask at 10 L/min.
C. Place the client in a Trendelenburg position.
D. Encourage the client to take deeper, faster breaths.
Correct Answer: A
Expert Explanation: These symptoms indicate that the client is hyperventilating,
which leads to respiratory alkalosis. Breathing into cupped hands or a paper bag
helps the client re-breathe carbon dioxide to restore balance. The nurse must
recognize these signs early to prevent further maternal distress. Proper breathing
techniques are essential non-pharmacologic methods for managing labor intensity.
Once the CO2 levels normalize, the tingling and lightheadedness will typically
resolve quickly.
,2. Following the administration of an epidural block, which assessment finding is the
most critical for the nurse to report to the provider immediately?
A. Maternal blood pressure decrease from 120/80 to 90/50 mmHg.
B. Maternal report of a localized itchy sensation on the chest.
C. Fetal heart rate showing moderate variability.
D. Client report of numbness in the lower extremities.
Correct Answer: A
Expert Explanation: Maternal hypotension is a common and potentially dangerous
side effect of epidural anesthesia due to sympathetic blockade. A significant drop in
blood pressure can decrease placental perfusion and lead to fetal hypoxia. The nurse
should immediately initiate corrective actions such as lateral positioning and
increasing IV fluids. Frequent monitoring of vital signs is mandatory during the first
15 to 30 minutes after placement. This prioritization ensures both maternal safety
and fetal well-being are maintained throughout the procedure.
3. The nurse is teaching a prenatal class about the Gate Control Theory of pain. Which
intervention should the nurse include as an application of this theory?
A. Administration of systemic opioid analgesics.
B. Performance of a pudendal nerve block during delivery.
C. Use of local infiltration for an episiotomy repair.
, D. Massaging the client’s back (effleurage) during contractions.
Correct Answer: D
Expert Explanation: The Gate Control Theory suggests that non-painful sensory
input can close the ‘gates’ to painful stimuli in the spinal cord. Effleurage, or light
rhythmic stroking of the abdomen or back, provides tactile stimulation that
competes with pain signals. This non-pharmacologic technique empowers the client
to manage discomfort without the side effects of medications. It is often used in
conjunction with controlled breathing to maximize relaxation. Education on these
techniques helps clients feel more prepared and in control during the labor process.
4. A client received an IV dose of butorphanol (Stadol) 30 minutes before delivery. The
nurse should ensure which medication is readily available in the delivery room?
A. Magnesium sulfate
B. Naloxone (Narcan)
C. Calcium gluconate
D. Oxytocin
Correct Answer: B
Expert Explanation: Opioid analgesics given close to delivery can cross the
placenta and cause respiratory depression in the neonate. Naloxone is the specific
antagonist used to reverse the effects of opioids in both the mother and the
Questions with Correct Answers and Expert
Explanation for Each Question | Saint Paul’s School
of Nursing
1. A client in the transition phase of labor is experiencing lightheadedness and tingling
in her fingers while using patterned-paced breathing. Which action should the nurse
take first?
A. Instruct the client to breathe into her cupped hands.
B. Administer oxygen via a non-rebreather mask at 10 L/min.
C. Place the client in a Trendelenburg position.
D. Encourage the client to take deeper, faster breaths.
Correct Answer: A
Expert Explanation: These symptoms indicate that the client is hyperventilating,
which leads to respiratory alkalosis. Breathing into cupped hands or a paper bag
helps the client re-breathe carbon dioxide to restore balance. The nurse must
recognize these signs early to prevent further maternal distress. Proper breathing
techniques are essential non-pharmacologic methods for managing labor intensity.
Once the CO2 levels normalize, the tingling and lightheadedness will typically
resolve quickly.
,2. Following the administration of an epidural block, which assessment finding is the
most critical for the nurse to report to the provider immediately?
A. Maternal blood pressure decrease from 120/80 to 90/50 mmHg.
B. Maternal report of a localized itchy sensation on the chest.
C. Fetal heart rate showing moderate variability.
D. Client report of numbness in the lower extremities.
Correct Answer: A
Expert Explanation: Maternal hypotension is a common and potentially dangerous
side effect of epidural anesthesia due to sympathetic blockade. A significant drop in
blood pressure can decrease placental perfusion and lead to fetal hypoxia. The nurse
should immediately initiate corrective actions such as lateral positioning and
increasing IV fluids. Frequent monitoring of vital signs is mandatory during the first
15 to 30 minutes after placement. This prioritization ensures both maternal safety
and fetal well-being are maintained throughout the procedure.
3. The nurse is teaching a prenatal class about the Gate Control Theory of pain. Which
intervention should the nurse include as an application of this theory?
A. Administration of systemic opioid analgesics.
B. Performance of a pudendal nerve block during delivery.
C. Use of local infiltration for an episiotomy repair.
, D. Massaging the client’s back (effleurage) during contractions.
Correct Answer: D
Expert Explanation: The Gate Control Theory suggests that non-painful sensory
input can close the ‘gates’ to painful stimuli in the spinal cord. Effleurage, or light
rhythmic stroking of the abdomen or back, provides tactile stimulation that
competes with pain signals. This non-pharmacologic technique empowers the client
to manage discomfort without the side effects of medications. It is often used in
conjunction with controlled breathing to maximize relaxation. Education on these
techniques helps clients feel more prepared and in control during the labor process.
4. A client received an IV dose of butorphanol (Stadol) 30 minutes before delivery. The
nurse should ensure which medication is readily available in the delivery room?
A. Magnesium sulfate
B. Naloxone (Narcan)
C. Calcium gluconate
D. Oxytocin
Correct Answer: B
Expert Explanation: Opioid analgesics given close to delivery can cross the
placenta and cause respiratory depression in the neonate. Naloxone is the specific
antagonist used to reverse the effects of opioids in both the mother and the
