NUR 230 Maternal Exam 2
Section 1: Intrapartum Care (Questions 1-30)
Question 1
A nurse is assessing a client in active labor. The fetal heart tracing shows recurrent
variable decelerations. Which action should the nurse take first?
A. Increase IV fluids
B. Change maternal position
C. Administer oxygen
D. Notify the provider
Answer: B. Change maternal position
Rationale: Variable decelerations are caused by cord compression. The first
intervention is to change the mother's position (typically to left lateral) to relieve
pressure on the cord.
Question 2
A client is 9 cm dilated, 100% effaced, and at +1 station. She reports an intense
urge to push. What should the nurse do?
A. Encourage her to push with contractions
B. Have her pant and avoid pushing until fully dilated
C. Apply fundal pressure during contractions
D. Prepare for immediate delivery
Answer: B. Have her pant and avoid pushing until fully dilated
Rationale: Pushing before complete dilation (10 cm) can cause cervical edema,
laceration, and prolonged labor. The nurse should instruct the client to use
breathing techniques to manage the urge.
Question 3
Which pelvic type is most favorable for vaginal birth?
A. Android
B. Anthropoid
,C. Gynecoid
D. Platypelloid
Answer: C. Gynecoid
Rationale: The gynecoid pelvis is rounded with adequate capacity, making it the
most favorable. Platypelloid (flat) is the least favorable.
Question 4
A primigravida at 40 weeks is receiving oxytocin. Contractions are lasting 110
seconds with 50 seconds between. What is the priority action?
A. Increase oxytocin
B. Position on left side
C. Stop oxytocin infusion
D. Administer oxygen
Answer: C. Stop oxytocin infusion
Rationale: Contractions lasting >90 seconds with <60 seconds rest indicate
tachysystole. Oxytocin must be stopped immediately to prevent uterine rupture
or fetal distress.
Question 5
A client has a cervical exam finding of 6 cm, 80%, –1. Which stage and phase of
labor is this?
A. First stage, latent phase
B. First stage, active phase
C. First stage, transition phase
D. Second stage
Answer: B. First stage, active phase
Rationale: Active phase is characterized by dilation from 4-7 cm with rapid
progress. Latent phase is 0-3 cm, transition is 8-10 cm.
Question 6
What is the normal fetal heart rate range for a term fetus?
,A. 80-100 bpm
B. 100-120 bpm
C. 110-160 bpm
D. 160-180 bpm
Answer: C. 110-160 bpm
Rationale: The normal baseline FHR for a term fetus is 110-160 beats per minute.
Question 7
A nurse notes late decelerations on the fetal monitor. Which is the priority
intervention?
A. Increase oxytocin
B. Reposition to left lateral
C. Prepare for immediate cesarean
D. Document the finding
Answer: B. Reposition to left lateral
Rationale: Late decelerations indicate uteroplacental insufficiency. Left lateral
position improves uterine blood flow. Oxygen and IV fluids may also be indicated.
Question 8
The nurse notes a fetal heart rate of 90 bpm lasting for 45 seconds after a
contraction. This is best described as:
A. Early deceleration
B. Late deceleration
C. Variable deceleration
D. Prolonged deceleration
Answer: D. Prolonged deceleration
Rationale: A prolonged deceleration lasts ≥2 minutes but <10 minutes, with a
decrease from baseline of ≥15 bpm.
Question 9
A client's amniotic membrane ruptures spontaneously. The nurse observes clear
, fluid with dark green streaks. The nurse should:
A. Document as normal
B. Notify the provider immediately
C. Administer oxygen to the mother
D. Prepare for amnioinfusion
Answer: B. Notify the provider immediately
Rationale: Green-tinged fluid indicates meconium, which can cause meconium
aspiration syndrome. The provider should be notified.
Question 10
Which fetal lie is most common and favorable for vaginal delivery?
A. Transverse lie
B. Oblique lie
C. Longitudinal lie
D. Breech lie
Answer: C. Longitudinal lie
Rationale: In longitudinal lie, the fetal spine is parallel to the maternal spine. This
is the most common and favorable for vaginal birth.
Question 11
The nurse is assessing a client's contraction pattern. Which finding requires
immediate intervention?
A. Duration 70 seconds, frequency every 3 minutes
B. Duration 100 seconds, frequency every 90 seconds
C. Duration 50 seconds, frequency every 4 minutes
D. Duration 60 seconds, frequency every 2.5 minutes
Answer: B. Duration 100 seconds, frequency every 90 seconds
Rationale: Contractions lasting >90 seconds with <60 seconds rest indicate
tachysystole and require intervention.
Section 1: Intrapartum Care (Questions 1-30)
Question 1
A nurse is assessing a client in active labor. The fetal heart tracing shows recurrent
variable decelerations. Which action should the nurse take first?
A. Increase IV fluids
B. Change maternal position
C. Administer oxygen
D. Notify the provider
Answer: B. Change maternal position
Rationale: Variable decelerations are caused by cord compression. The first
intervention is to change the mother's position (typically to left lateral) to relieve
pressure on the cord.
Question 2
A client is 9 cm dilated, 100% effaced, and at +1 station. She reports an intense
urge to push. What should the nurse do?
A. Encourage her to push with contractions
B. Have her pant and avoid pushing until fully dilated
C. Apply fundal pressure during contractions
D. Prepare for immediate delivery
Answer: B. Have her pant and avoid pushing until fully dilated
Rationale: Pushing before complete dilation (10 cm) can cause cervical edema,
laceration, and prolonged labor. The nurse should instruct the client to use
breathing techniques to manage the urge.
Question 3
Which pelvic type is most favorable for vaginal birth?
A. Android
B. Anthropoid
,C. Gynecoid
D. Platypelloid
Answer: C. Gynecoid
Rationale: The gynecoid pelvis is rounded with adequate capacity, making it the
most favorable. Platypelloid (flat) is the least favorable.
Question 4
A primigravida at 40 weeks is receiving oxytocin. Contractions are lasting 110
seconds with 50 seconds between. What is the priority action?
A. Increase oxytocin
B. Position on left side
C. Stop oxytocin infusion
D. Administer oxygen
Answer: C. Stop oxytocin infusion
Rationale: Contractions lasting >90 seconds with <60 seconds rest indicate
tachysystole. Oxytocin must be stopped immediately to prevent uterine rupture
or fetal distress.
Question 5
A client has a cervical exam finding of 6 cm, 80%, –1. Which stage and phase of
labor is this?
A. First stage, latent phase
B. First stage, active phase
C. First stage, transition phase
D. Second stage
Answer: B. First stage, active phase
Rationale: Active phase is characterized by dilation from 4-7 cm with rapid
progress. Latent phase is 0-3 cm, transition is 8-10 cm.
Question 6
What is the normal fetal heart rate range for a term fetus?
,A. 80-100 bpm
B. 100-120 bpm
C. 110-160 bpm
D. 160-180 bpm
Answer: C. 110-160 bpm
Rationale: The normal baseline FHR for a term fetus is 110-160 beats per minute.
Question 7
A nurse notes late decelerations on the fetal monitor. Which is the priority
intervention?
A. Increase oxytocin
B. Reposition to left lateral
C. Prepare for immediate cesarean
D. Document the finding
Answer: B. Reposition to left lateral
Rationale: Late decelerations indicate uteroplacental insufficiency. Left lateral
position improves uterine blood flow. Oxygen and IV fluids may also be indicated.
Question 8
The nurse notes a fetal heart rate of 90 bpm lasting for 45 seconds after a
contraction. This is best described as:
A. Early deceleration
B. Late deceleration
C. Variable deceleration
D. Prolonged deceleration
Answer: D. Prolonged deceleration
Rationale: A prolonged deceleration lasts ≥2 minutes but <10 minutes, with a
decrease from baseline of ≥15 bpm.
Question 9
A client's amniotic membrane ruptures spontaneously. The nurse observes clear
, fluid with dark green streaks. The nurse should:
A. Document as normal
B. Notify the provider immediately
C. Administer oxygen to the mother
D. Prepare for amnioinfusion
Answer: B. Notify the provider immediately
Rationale: Green-tinged fluid indicates meconium, which can cause meconium
aspiration syndrome. The provider should be notified.
Question 10
Which fetal lie is most common and favorable for vaginal delivery?
A. Transverse lie
B. Oblique lie
C. Longitudinal lie
D. Breech lie
Answer: C. Longitudinal lie
Rationale: In longitudinal lie, the fetal spine is parallel to the maternal spine. This
is the most common and favorable for vaginal birth.
Question 11
The nurse is assessing a client's contraction pattern. Which finding requires
immediate intervention?
A. Duration 70 seconds, frequency every 3 minutes
B. Duration 100 seconds, frequency every 90 seconds
C. Duration 50 seconds, frequency every 4 minutes
D. Duration 60 seconds, frequency every 2.5 minutes
Answer: B. Duration 100 seconds, frequency every 90 seconds
Rationale: Contractions lasting >90 seconds with <60 seconds rest indicate
tachysystole and require intervention.
