NUR 230 Maternal Exam 2 |
Galen College of Nursing
1. The nurse is assessing the physiological changes in the newborn. Which of
the following is the correct order of the changes?
a. Successful feeding
b. Thermoregulation
c. Extra-uterine growth
d. Spontaneous breathing
Answer: d, b, a, c (Spontaneous breathing → Thermoregulation →
Successful feeding → Extra-uterine growth)
2. The nurse is caring for a patient who is in the process of giving birth. Which
of the following is the correct order of the changes?
a. Place a hat on the patient
b. Utilize a clean cloth to wipe the patient's face
Answer: b, a (Wipe face first to stimulate breathing, then place a hat to
prevent heat loss)
3. A nurse is assessing a newborn 1 minute after birth. Which finding would
receive an Apgar score of 2?
a. Heart rate of 90 bpm
b. Acrocyanosis
c. Grimace during suctioning
d. Active movement with flexed extremities
Answer: d. Active movement with flexed extremities
4. A patient at 38 weeks gestation is receiving an intravenous infusion of
oxytocin (Pitocin). The nurse notes the uterine contractions are every 1.5
minutes, lasting 100 seconds. What is the priority nursing action?
a. Increase the oxytocin infusion rate
b. Position the patient on the left side and stop the infusion
c. Apply oxygen via nasal cannula at 2 L/min
, d. Document the findings as a normal labor pattern
Answer: b. Position the patient on the left side and stop the infusion
5. The nurse is providing education to a patient with gestational diabetes.
Which maternal complication is most strongly associated with poor
glycemic control?
a. Placenta previa
b. Preterm labor
c. Macrosomia
d. Oligohydramnios
Answer: c. Macrosomia
6. A nurse is assessing a patient in active labor. The fetal heart rate tracing
shows a decrease in FHR that begins just after the contraction starts and
returns to baseline by the end of the contraction. This pattern is best
described as:
a. Early deceleration
b. Late deceleration
c. Variable deceleration
d. Prolonged deceleration
Answer: a. Early deceleration
7. A postpartum patient reports a sudden, severe, tearing perineal pain. The
nurse assesses a large, tense, bulging mass on the vulva. These findings are
most consistent with which complication?
a. Uterine inversion
b. Retained placental fragment
c. Perineal hematoma
d. Endometritis
Answer: c. Perineal hematoma
8. Which medication should the nurse anticipate administering to a patient with
severe preeclampsia to prevent seizures?
a. Terbutaline sulfate
b. Magnesium sulfate
c. Betamethasone
d. Nifedipine
Answer: b. Magnesium sulfate
,9. A nurse is caring for a patient with a third-degree perineal laceration. Which
sign or symptom would indicate a developing rectovaginal fistula?
a. Fever and chills
b. Passage of flatus or stool from the vagina
c. Severe pain unrelieved by analgesics
d. Dark red lochia with large clots
Answer: b. Passage of flatus or stool from the vagina
10.The nurse notes that a patient's fundus is boggy and displaced to the right
side. What is the priority nursing action?
a. Administer oxytocin IV
b. Massage the fundus and assist the patient to void
c. Notify the healthcare provider immediately
d. Increase the rate of the IV fluid infusion
Answer: b. Massage the fundus and assist the patient to void
11.A newborn's blood glucose level is 35 mg/dL. Which of the following
actions should the nurse take first?
a. Administer intravenous dextrose 10% via bolus
b. Feed the newborn breastmilk or formula
c. Notify the neonatal intensive care unit provider
d. Recheck the blood glucose level in 2 hours
Answer: b. Feed the newborn breastmilk or formula
12.The nurse is assessing a patient who is 12 hours post-cesarean section.
Which finding requires immediate notification of the healthcare provider?
a. Pain rated as 5/10 at the incision site
b. Urine output of 80 mL over the last 2 hours
c. Temperature of 99.8°F (37.7°C)
d. Saturation of two perineal pads in 15 minutes
Answer: d. Saturation of two perineal pads in 15 minutes
13.A patient at 35 weeks gestation presents with painless, bright red vaginal
bleeding. The nurse should first suspect:
a. Abruptio placentae
b. Placenta previa
c. Uterine rupture
d. Vasa previa
Answer: b. Placenta previa
, 14.The nurse is teaching a new mother about signs of effective breastfeeding.
Which observation indicates that the baby is latching effectively?
a. The baby's lips are tucked inward
b. A clicking sound is heard during feeding
c. The baby's mouth covers the entire areola
d. The mother reports pain that lasts the entire feeding
Answer: c. The baby's mouth covers the entire areola
15.A nurse is reviewing laboratory results for a patient who is 24 hours
postpartum. Which finding is most concerning?
a. White blood cell count of 18,000/mm³
b. Hematocrit of 28%, down from 36% pre-birth
c. Platelet count of 80,000/mm³
d. Hemoglobin of 11 g/dL
Answer: c. Platelet count of 80,000/mm³
16.The nurse is caring for a patient with an intrauterine fetal demise. Which
nursing intervention is most appropriate to promote bonding and grieving?
a. Avoid discussing the baby to prevent further emotional distress
b. Remove the baby from the room immediately after birth
c. Encourage the patient and family to see, hold, and name the baby if they
wish
d. Recommend that the patient not see the baby to avoid traumatic memories
Answer: c. Encourage the patient and family to see, hold, and name the
baby if they wish
17.A patient in labor requests an epidural for pain relief. Which assessment
finding would contraindicate placement of an epidural?
a. Platelet count of 85,000/mm³
b. Blood pressure of 120/80 mm Hg
c. Cervical dilation of 4 cm
d. Maternal fever of 100.4°F (38°C)
Answer: a. Platelet count of 85,000/mm³
18.The nurse is assessing a newborn for signs of respiratory distress. Which
finding would be most concerning?
a. Nasal flaring
b. Grunting on expiration
c. Respiratory rate of 55 breaths per minute
Galen College of Nursing
1. The nurse is assessing the physiological changes in the newborn. Which of
the following is the correct order of the changes?
a. Successful feeding
b. Thermoregulation
c. Extra-uterine growth
d. Spontaneous breathing
Answer: d, b, a, c (Spontaneous breathing → Thermoregulation →
Successful feeding → Extra-uterine growth)
2. The nurse is caring for a patient who is in the process of giving birth. Which
of the following is the correct order of the changes?
a. Place a hat on the patient
b. Utilize a clean cloth to wipe the patient's face
Answer: b, a (Wipe face first to stimulate breathing, then place a hat to
prevent heat loss)
3. A nurse is assessing a newborn 1 minute after birth. Which finding would
receive an Apgar score of 2?
a. Heart rate of 90 bpm
b. Acrocyanosis
c. Grimace during suctioning
d. Active movement with flexed extremities
Answer: d. Active movement with flexed extremities
4. A patient at 38 weeks gestation is receiving an intravenous infusion of
oxytocin (Pitocin). The nurse notes the uterine contractions are every 1.5
minutes, lasting 100 seconds. What is the priority nursing action?
a. Increase the oxytocin infusion rate
b. Position the patient on the left side and stop the infusion
c. Apply oxygen via nasal cannula at 2 L/min
, d. Document the findings as a normal labor pattern
Answer: b. Position the patient on the left side and stop the infusion
5. The nurse is providing education to a patient with gestational diabetes.
Which maternal complication is most strongly associated with poor
glycemic control?
a. Placenta previa
b. Preterm labor
c. Macrosomia
d. Oligohydramnios
Answer: c. Macrosomia
6. A nurse is assessing a patient in active labor. The fetal heart rate tracing
shows a decrease in FHR that begins just after the contraction starts and
returns to baseline by the end of the contraction. This pattern is best
described as:
a. Early deceleration
b. Late deceleration
c. Variable deceleration
d. Prolonged deceleration
Answer: a. Early deceleration
7. A postpartum patient reports a sudden, severe, tearing perineal pain. The
nurse assesses a large, tense, bulging mass on the vulva. These findings are
most consistent with which complication?
a. Uterine inversion
b. Retained placental fragment
c. Perineal hematoma
d. Endometritis
Answer: c. Perineal hematoma
8. Which medication should the nurse anticipate administering to a patient with
severe preeclampsia to prevent seizures?
a. Terbutaline sulfate
b. Magnesium sulfate
c. Betamethasone
d. Nifedipine
Answer: b. Magnesium sulfate
,9. A nurse is caring for a patient with a third-degree perineal laceration. Which
sign or symptom would indicate a developing rectovaginal fistula?
a. Fever and chills
b. Passage of flatus or stool from the vagina
c. Severe pain unrelieved by analgesics
d. Dark red lochia with large clots
Answer: b. Passage of flatus or stool from the vagina
10.The nurse notes that a patient's fundus is boggy and displaced to the right
side. What is the priority nursing action?
a. Administer oxytocin IV
b. Massage the fundus and assist the patient to void
c. Notify the healthcare provider immediately
d. Increase the rate of the IV fluid infusion
Answer: b. Massage the fundus and assist the patient to void
11.A newborn's blood glucose level is 35 mg/dL. Which of the following
actions should the nurse take first?
a. Administer intravenous dextrose 10% via bolus
b. Feed the newborn breastmilk or formula
c. Notify the neonatal intensive care unit provider
d. Recheck the blood glucose level in 2 hours
Answer: b. Feed the newborn breastmilk or formula
12.The nurse is assessing a patient who is 12 hours post-cesarean section.
Which finding requires immediate notification of the healthcare provider?
a. Pain rated as 5/10 at the incision site
b. Urine output of 80 mL over the last 2 hours
c. Temperature of 99.8°F (37.7°C)
d. Saturation of two perineal pads in 15 minutes
Answer: d. Saturation of two perineal pads in 15 minutes
13.A patient at 35 weeks gestation presents with painless, bright red vaginal
bleeding. The nurse should first suspect:
a. Abruptio placentae
b. Placenta previa
c. Uterine rupture
d. Vasa previa
Answer: b. Placenta previa
, 14.The nurse is teaching a new mother about signs of effective breastfeeding.
Which observation indicates that the baby is latching effectively?
a. The baby's lips are tucked inward
b. A clicking sound is heard during feeding
c. The baby's mouth covers the entire areola
d. The mother reports pain that lasts the entire feeding
Answer: c. The baby's mouth covers the entire areola
15.A nurse is reviewing laboratory results for a patient who is 24 hours
postpartum. Which finding is most concerning?
a. White blood cell count of 18,000/mm³
b. Hematocrit of 28%, down from 36% pre-birth
c. Platelet count of 80,000/mm³
d. Hemoglobin of 11 g/dL
Answer: c. Platelet count of 80,000/mm³
16.The nurse is caring for a patient with an intrauterine fetal demise. Which
nursing intervention is most appropriate to promote bonding and grieving?
a. Avoid discussing the baby to prevent further emotional distress
b. Remove the baby from the room immediately after birth
c. Encourage the patient and family to see, hold, and name the baby if they
wish
d. Recommend that the patient not see the baby to avoid traumatic memories
Answer: c. Encourage the patient and family to see, hold, and name the
baby if they wish
17.A patient in labor requests an epidural for pain relief. Which assessment
finding would contraindicate placement of an epidural?
a. Platelet count of 85,000/mm³
b. Blood pressure of 120/80 mm Hg
c. Cervical dilation of 4 cm
d. Maternal fever of 100.4°F (38°C)
Answer: a. Platelet count of 85,000/mm³
18.The nurse is assessing a newborn for signs of respiratory distress. Which
finding would be most concerning?
a. Nasal flaring
b. Grunting on expiration
c. Respiratory rate of 55 breaths per minute
