NURS 203 | NURS 203 Maternity Exam 2 Version 3 |
Questions with Correct Answers and Expert
Explanation for Each Question | Saint Paul’s School
of Nursing
1. A client at 12 weeks gestation is admitted with hyperemesis gravidarum. Which of
the following laboratory findings should the nurse expect?
A. Decreased hemoglobin levels
B. Hypoglycemia
C. Ketonuria
D. Respiratory acidosis
Correct Answer: C
Expert Explanation: Hyperemesis gravidarum leads to severe vomiting and
inadequate nutritional intake. This condition causes the body to break down stored
fat for energy, resulting in the presence of ketones in the urine. The nurse must
monitor for ketonuria as it indicates a state of starvation and metabolic imbalance.
Initial treatment focuses on restoring hydration and electrolyte stability to prevent
further complications. Other options like respiratory acidosis are incorrect because
vomiting typically leads to metabolic alkalosis.
,2. An Rh-negative mother has just given birth to an Rh-positive infant. Which action
should the nurse prioritize?
A. Administer Rho(D) immune globulin within 72 hours
B. Obtain a direct Coombs test from the mother
C. Monitor the infant for signs of hypercalcemia
D. Prepare for an immediate exchange transfusion for the mother
Correct Answer: A
Expert Explanation: Rho(D) immune globulin is administered to prevent the
mother from forming antibodies against Rh-positive fetal blood cells. This
intervention is critical for protecting future pregnancies from hemolytic disease of
the newborn. The standard protocol requires administration within 72 hours of
delivery when the infant is Rh-positive. The indirect Coombs test is performed on
the mother, whereas the direct Coombs is performed on the infant. Providing this
medication ensures maternal sensitization does not occur during this postpartum
window.
3. A nurse is caring for a client receiving magnesium sulfate for preeclampsia. Which
assessment finding requires immediate notification of the provider?
A. Urine output of 40 mL per hour
B. Respiratory rate of 10 breaths per minute
,C. Deep tendon reflexes of 2+
D. Fetal heart rate of 140 beats per minute
Correct Answer: B
Expert Explanation: Magnesium sulfate is a central nervous system depressant
used to prevent seizures in preeclampsia. A respiratory rate below 12 breaths per
minute is a primary indicator of magnesium toxicity and impending respiratory
failure. The nurse must immediately stop the infusion and prepare the antidote if
this occurs. Adequate urine output and normal reflexes suggest the medication is at
a therapeutic level without toxicity. Prompt recognition of respiratory depression is
essential for ensuring maternal safety during high-risk therapy.
4. A pregnant client at 32 weeks gestation presents with painless, bright red vaginal
bleeding. Which of the following is the most likely diagnosis?
A. Abruptio placentae
B. Placenta previa
C. Hydatidiform mole
D. Ectopic pregnancy
Correct Answer: B
, Expert Explanation: Placenta previa is characterized by the placenta covering the
cervical os, often presenting with painless bleeding in the third trimester. In
contrast, abruptio placentae involves painful bleeding and a rigid abdomen due to
premature separation. The lack of pain is the hallmark clinical indicator that
differentiates previa from other late-pregnancy bleeding complications. Nursing
management includes strict pelvic rest and avoiding vaginal examinations to
prevent further hemorrhage. Ultrasound is the definitive diagnostic tool used to
confirm placental placement in these scenarios.
5. Which medication is the antidote for magnesium sulfate toxicity?
A. Naloxone
B. Terbutaline
C. Calcium gluconate
D. Oxytocin
Correct Answer: C
Expert Explanation: Calcium gluconate is the specific pharmacological antagonist
used to reverse the effects of magnesium sulfate toxicity. If signs of toxicity like
absent reflexes or respiratory distress appear, this medication should be
administered intravenously. It works by displacing magnesium from the
neuromuscular junctions to restore normal function. Nurses must keep this
Questions with Correct Answers and Expert
Explanation for Each Question | Saint Paul’s School
of Nursing
1. A client at 12 weeks gestation is admitted with hyperemesis gravidarum. Which of
the following laboratory findings should the nurse expect?
A. Decreased hemoglobin levels
B. Hypoglycemia
C. Ketonuria
D. Respiratory acidosis
Correct Answer: C
Expert Explanation: Hyperemesis gravidarum leads to severe vomiting and
inadequate nutritional intake. This condition causes the body to break down stored
fat for energy, resulting in the presence of ketones in the urine. The nurse must
monitor for ketonuria as it indicates a state of starvation and metabolic imbalance.
Initial treatment focuses on restoring hydration and electrolyte stability to prevent
further complications. Other options like respiratory acidosis are incorrect because
vomiting typically leads to metabolic alkalosis.
,2. An Rh-negative mother has just given birth to an Rh-positive infant. Which action
should the nurse prioritize?
A. Administer Rho(D) immune globulin within 72 hours
B. Obtain a direct Coombs test from the mother
C. Monitor the infant for signs of hypercalcemia
D. Prepare for an immediate exchange transfusion for the mother
Correct Answer: A
Expert Explanation: Rho(D) immune globulin is administered to prevent the
mother from forming antibodies against Rh-positive fetal blood cells. This
intervention is critical for protecting future pregnancies from hemolytic disease of
the newborn. The standard protocol requires administration within 72 hours of
delivery when the infant is Rh-positive. The indirect Coombs test is performed on
the mother, whereas the direct Coombs is performed on the infant. Providing this
medication ensures maternal sensitization does not occur during this postpartum
window.
3. A nurse is caring for a client receiving magnesium sulfate for preeclampsia. Which
assessment finding requires immediate notification of the provider?
A. Urine output of 40 mL per hour
B. Respiratory rate of 10 breaths per minute
,C. Deep tendon reflexes of 2+
D. Fetal heart rate of 140 beats per minute
Correct Answer: B
Expert Explanation: Magnesium sulfate is a central nervous system depressant
used to prevent seizures in preeclampsia. A respiratory rate below 12 breaths per
minute is a primary indicator of magnesium toxicity and impending respiratory
failure. The nurse must immediately stop the infusion and prepare the antidote if
this occurs. Adequate urine output and normal reflexes suggest the medication is at
a therapeutic level without toxicity. Prompt recognition of respiratory depression is
essential for ensuring maternal safety during high-risk therapy.
4. A pregnant client at 32 weeks gestation presents with painless, bright red vaginal
bleeding. Which of the following is the most likely diagnosis?
A. Abruptio placentae
B. Placenta previa
C. Hydatidiform mole
D. Ectopic pregnancy
Correct Answer: B
, Expert Explanation: Placenta previa is characterized by the placenta covering the
cervical os, often presenting with painless bleeding in the third trimester. In
contrast, abruptio placentae involves painful bleeding and a rigid abdomen due to
premature separation. The lack of pain is the hallmark clinical indicator that
differentiates previa from other late-pregnancy bleeding complications. Nursing
management includes strict pelvic rest and avoiding vaginal examinations to
prevent further hemorrhage. Ultrasound is the definitive diagnostic tool used to
confirm placental placement in these scenarios.
5. Which medication is the antidote for magnesium sulfate toxicity?
A. Naloxone
B. Terbutaline
C. Calcium gluconate
D. Oxytocin
Correct Answer: C
Expert Explanation: Calcium gluconate is the specific pharmacological antagonist
used to reverse the effects of magnesium sulfate toxicity. If signs of toxicity like
absent reflexes or respiratory distress appear, this medication should be
administered intravenously. It works by displacing magnesium from the
neuromuscular junctions to restore normal function. Nurses must keep this
