NURS 203 | NURS 203 Maternity Exam 2 Version 2 |
Questions with Correct Answers and Expert
Explanation for Each Question | Saint Paul’s School
of Nursing
1. A nurse is assessing a client at 34 weeks gestation who presents with painless,
bright red vaginal bleeding. Which condition should the nurse suspect?
A. Placental abruption
B. Placenta previa
C. Ruptured ectopic pregnancy
D. Preterm labor
Correct Answer: B
Expert Explanation: Placenta previa is characterized by the onset of painless,
bright red vaginal bleeding during the second or third trimester. This occurs
because the placenta is implanted over or near the internal cervical os. In contrast,
placental abruption usually presents with painful bleeding and a rigid abdomen. The
nurse must avoid performing a vaginal exam until ultrasound confirms placental
location to prevent severe hemorrhage. Management focuses on bed rest and
continuous monitoring of fetal well-being.
,2. A nurse is caring for a client with placental abruption. Which of the following clinical
findings is most characteristic of this condition?
A. Board-like, tender abdomen
B. Soft, non-tender uterus
C. Decreased blood pressure with no pain
D. Painless cervical dilation
Correct Answer: A
Expert Explanation: Placental abruption involves the premature separation of the
placenta from the uterine wall, leading to internal bleeding. This hemorrhage causes
uterine irritability and a classic ‘board-like’ or rigid, tender abdomen. Pain is
typically sudden and severe, unlike the painless bleeding seen in previa. Fetal
distress often follows due to the lack of oxygenated blood flow to the fetus. The
nurse must prioritize monitoring maternal hemodynamic stability and preparing for
potential emergency delivery.
3. A client at 32 weeks gestation is receiving Magnesium Sulfate for preeclampsia.
Which assessment finding should the nurse report immediately?
A. Deep tendon reflexes of 2+
B. Respiratory rate of 10 breaths per minute
C. Urinary output of 40 mL per hour
,D. Fetal heart rate of 140 bpm
Correct Answer: B
Expert Explanation: Magnesium sulfate is a central nervous system depressant
used to prevent seizures in preeclamptic patients. A respiratory rate below 12
breaths per minute is a primary indicator of magnesium toxicity. The nurse must
also monitor for loss of deep tendon reflexes and a significant drop in urinary
output. If toxicity is suspected, the infusion must be stopped immediately and the
healthcare provider notified. Calcium gluconate should be kept at the bedside as the
pharmacological antidote for magnesium toxicity.
4. Which medication is typically administered to a client at 28 weeks gestation who is
at risk for preterm delivery to promote fetal lung maturity?
A. Oxytocin
B. Indomethacin
C. Terbutaline
D. Betamethasone
Correct Answer: D
Expert Explanation: Betamethasone is a corticosteroid given to pregnant women
between 24 and 34 weeks of gestation who are at risk of preterm birth. Its primary
function is to stimulate the production of surfactant in the fetal lungs. This helps
, prevent neonatal respiratory distress syndrome and other complications of
prematurity. The medication is usually given in two doses 24 hours apart for
maximum effectiveness. The nurse should monitor maternal blood glucose levels, as
steroids can cause transient hyperglycemia.
5. A nurse is monitoring a client with severe preeclampsia. Which laboratory result is
indicative of HELLP syndrome?
A. Elevated hemoglobin and hematocrit
B. Decreased liver enzymes (AST/ALT)
C. Platelet count of 80,000/mm³
D. Decreased serum creatinine
Correct Answer: C
Expert Explanation: HELLP syndrome stands for Hemolysis, Elevated Liver
enzymes, and Low Platelets. A platelet count below 100,000/mm³ is a diagnostic
criterion for this severe complication of pregnancy. Hemolysis results in abnormal
red blood cell fragments, while elevated AST/ALT indicate liver damage. This
condition represents a significant risk for maternal morbidity and mortality.
Immediate stabilization and delivery of the fetus are often required to resolve the
condition.
Questions with Correct Answers and Expert
Explanation for Each Question | Saint Paul’s School
of Nursing
1. A nurse is assessing a client at 34 weeks gestation who presents with painless,
bright red vaginal bleeding. Which condition should the nurse suspect?
A. Placental abruption
B. Placenta previa
C. Ruptured ectopic pregnancy
D. Preterm labor
Correct Answer: B
Expert Explanation: Placenta previa is characterized by the onset of painless,
bright red vaginal bleeding during the second or third trimester. This occurs
because the placenta is implanted over or near the internal cervical os. In contrast,
placental abruption usually presents with painful bleeding and a rigid abdomen. The
nurse must avoid performing a vaginal exam until ultrasound confirms placental
location to prevent severe hemorrhage. Management focuses on bed rest and
continuous monitoring of fetal well-being.
,2. A nurse is caring for a client with placental abruption. Which of the following clinical
findings is most characteristic of this condition?
A. Board-like, tender abdomen
B. Soft, non-tender uterus
C. Decreased blood pressure with no pain
D. Painless cervical dilation
Correct Answer: A
Expert Explanation: Placental abruption involves the premature separation of the
placenta from the uterine wall, leading to internal bleeding. This hemorrhage causes
uterine irritability and a classic ‘board-like’ or rigid, tender abdomen. Pain is
typically sudden and severe, unlike the painless bleeding seen in previa. Fetal
distress often follows due to the lack of oxygenated blood flow to the fetus. The
nurse must prioritize monitoring maternal hemodynamic stability and preparing for
potential emergency delivery.
3. A client at 32 weeks gestation is receiving Magnesium Sulfate for preeclampsia.
Which assessment finding should the nurse report immediately?
A. Deep tendon reflexes of 2+
B. Respiratory rate of 10 breaths per minute
C. Urinary output of 40 mL per hour
,D. Fetal heart rate of 140 bpm
Correct Answer: B
Expert Explanation: Magnesium sulfate is a central nervous system depressant
used to prevent seizures in preeclamptic patients. A respiratory rate below 12
breaths per minute is a primary indicator of magnesium toxicity. The nurse must
also monitor for loss of deep tendon reflexes and a significant drop in urinary
output. If toxicity is suspected, the infusion must be stopped immediately and the
healthcare provider notified. Calcium gluconate should be kept at the bedside as the
pharmacological antidote for magnesium toxicity.
4. Which medication is typically administered to a client at 28 weeks gestation who is
at risk for preterm delivery to promote fetal lung maturity?
A. Oxytocin
B. Indomethacin
C. Terbutaline
D. Betamethasone
Correct Answer: D
Expert Explanation: Betamethasone is a corticosteroid given to pregnant women
between 24 and 34 weeks of gestation who are at risk of preterm birth. Its primary
function is to stimulate the production of surfactant in the fetal lungs. This helps
, prevent neonatal respiratory distress syndrome and other complications of
prematurity. The medication is usually given in two doses 24 hours apart for
maximum effectiveness. The nurse should monitor maternal blood glucose levels, as
steroids can cause transient hyperglycemia.
5. A nurse is monitoring a client with severe preeclampsia. Which laboratory result is
indicative of HELLP syndrome?
A. Elevated hemoglobin and hematocrit
B. Decreased liver enzymes (AST/ALT)
C. Platelet count of 80,000/mm³
D. Decreased serum creatinine
Correct Answer: C
Expert Explanation: HELLP syndrome stands for Hemolysis, Elevated Liver
enzymes, and Low Platelets. A platelet count below 100,000/mm³ is a diagnostic
criterion for this severe complication of pregnancy. Hemolysis results in abnormal
red blood cell fragments, while elevated AST/ALT indicate liver damage. This
condition represents a significant risk for maternal morbidity and mortality.
Immediate stabilization and delivery of the fetus are often required to resolve the
condition.
