NUR254 MATERNITY EXAM 2, 2025 QUESTIONS,
ANSWERS and RATIONALES
1. Question:
A 28-year-old woman at 28 weeks of gestation reports feeling faint and
lightheaded when she lies flat on her back. Which of the following is the most
likely explanation for her symptoms?
a) Hypotension
b) Postural hypotension
c) Supine hypotensive syndrome
d) Anemia
Answer:
c) Supine hypotensive syndrome
Rationale:
Supine hypotensive syndrome occurs when the gravid uterus compresses the
inferior vena cava when the woman is lying on her back, reducing venous return to
the heart and causing hypotension, dizziness, and lightheadedness. This is common
after the 20th week of pregnancy, and the symptoms improve when the woman
shifts to her left side.
2. Question:
Which of the following is the primary purpose of folic acid supplementation during
pregnancy?
a) To prevent neural tube defects
b) To increase maternal iron stores
c) To reduce the risk of gestational diabetes
d) To prevent preterm labor
Answer:
a) To prevent neural tube defects
,Rationale:
Folic acid supplementation during pregnancy is essential in preventing neural tube
defects, such as spina bifida and anencephaly. It is typically recommended that
women take 400-800 mcg of folic acid daily, starting before conception and
continuing through the first trimester.
3. Question:
A patient at 38 weeks' gestation is experiencing regular contractions every 5
minutes and reports a gush of fluid from the vagina. Which action should the nurse
take first?
a) Perform a vaginal examination to check for dilation
b) Assess fetal heart tones
c) Prepare the patient for an immediate cesarean delivery
d) Administer IV fluids to the mother
Answer:
b) Assess fetal heart tones
Rationale:
The first priority in labor is to assess fetal well-being. A gush of fluid may indicate
rupture of membranes, and the nurse should immediately assess the fetal heart
tones to ensure that the fetus is tolerating the labor process. Only after assessing
fetal status should other interventions be considered.
4. Question:
A postpartum patient is concerned about breastfeeding and asks when she will start
producing milk. What is the nurse's best response?
a) "Milk production starts immediately after delivery."
b) "It can take 3 to 5 days after delivery for your milk to come in."
c) "Milk production usually starts around 6 weeks postpartum."
d) "You will not produce milk until your baby begins sucking regularly."
,Answer:
b) "It can take 3 to 5 days after delivery for your milk to come in."
Rationale:
After childbirth, women typically experience colostrum production initially, which
is a thick, yellowish fluid that is rich in antibodies. Full milk production, however,
generally begins 3 to 5 days after delivery, as hormonal changes stimulate the
production of milk.
5. Question:
A client at 32 weeks gestation presents with sudden-onset abdominal pain, vaginal
bleeding, and a rigid abdomen. Which condition does this most likely indicate?
a) Placenta previa
b) Placental abruption
c) Ectopic pregnancy
d) Preterm labor
Answer:
b) Placental abruption
Rationale:
Placental abruption is the premature separation of the placenta from the uterine
wall, typically presenting with sudden abdominal pain, vaginal bleeding, and a
rigid, board-like abdomen. This is a medical emergency and requires immediate
intervention to stabilize the mother and fetus.
6. Question:
A nurse is preparing a teaching plan for a pregnant woman who is in her first
trimester. Which of the following instructions should be included regarding
nutrition?
a) "Increase your intake of high-protein foods to support fetal development."
b) "You should consume 500 additional calories per day during the first trimester."
, c) "Avoid dairy products, as they can increase the risk of gestational diabetes."
d) "Take prenatal vitamins that include folic acid to prevent neural tube defects."
Answer:
d) "Take prenatal vitamins that include folic acid to prevent neural tube
defects."
Rationale:
During the first trimester, the most important nutritional consideration is ensuring
adequate intake of folic acid, which helps prevent neural tube defects. The
increased caloric intake is typically recommended during the second and third
trimesters, not the first. Additionally, dairy is generally encouraged for its calcium
content unless contraindicated.
7. Question:
A nurse is caring for a client who is 24 hours postpartum and is experiencing a
fever of 101°F (38.3°C). The nurse suspects a postpartum infection. Which of the
following interventions should be a priority?
a) Administering a prescribed antipyretic
b) Performing a breast examination for signs of mastitis
c) Monitoring for signs of deep vein thrombosis (DVT)
d) Encouraging early ambulation
Answer:
b) Performing a breast examination for signs of mastitis
Rationale:
A fever in the early postpartum period could indicate an infection such as mastitis
(infection of the breast tissue), urinary tract infection, or endometritis. Mastitis
commonly presents with localized breast pain, redness, and flu-like symptoms. A
breast exam is a priority to rule out this infection, and the nurse should also assess
other potential infection sources.
8. Question:
ANSWERS and RATIONALES
1. Question:
A 28-year-old woman at 28 weeks of gestation reports feeling faint and
lightheaded when she lies flat on her back. Which of the following is the most
likely explanation for her symptoms?
a) Hypotension
b) Postural hypotension
c) Supine hypotensive syndrome
d) Anemia
Answer:
c) Supine hypotensive syndrome
Rationale:
Supine hypotensive syndrome occurs when the gravid uterus compresses the
inferior vena cava when the woman is lying on her back, reducing venous return to
the heart and causing hypotension, dizziness, and lightheadedness. This is common
after the 20th week of pregnancy, and the symptoms improve when the woman
shifts to her left side.
2. Question:
Which of the following is the primary purpose of folic acid supplementation during
pregnancy?
a) To prevent neural tube defects
b) To increase maternal iron stores
c) To reduce the risk of gestational diabetes
d) To prevent preterm labor
Answer:
a) To prevent neural tube defects
,Rationale:
Folic acid supplementation during pregnancy is essential in preventing neural tube
defects, such as spina bifida and anencephaly. It is typically recommended that
women take 400-800 mcg of folic acid daily, starting before conception and
continuing through the first trimester.
3. Question:
A patient at 38 weeks' gestation is experiencing regular contractions every 5
minutes and reports a gush of fluid from the vagina. Which action should the nurse
take first?
a) Perform a vaginal examination to check for dilation
b) Assess fetal heart tones
c) Prepare the patient for an immediate cesarean delivery
d) Administer IV fluids to the mother
Answer:
b) Assess fetal heart tones
Rationale:
The first priority in labor is to assess fetal well-being. A gush of fluid may indicate
rupture of membranes, and the nurse should immediately assess the fetal heart
tones to ensure that the fetus is tolerating the labor process. Only after assessing
fetal status should other interventions be considered.
4. Question:
A postpartum patient is concerned about breastfeeding and asks when she will start
producing milk. What is the nurse's best response?
a) "Milk production starts immediately after delivery."
b) "It can take 3 to 5 days after delivery for your milk to come in."
c) "Milk production usually starts around 6 weeks postpartum."
d) "You will not produce milk until your baby begins sucking regularly."
,Answer:
b) "It can take 3 to 5 days after delivery for your milk to come in."
Rationale:
After childbirth, women typically experience colostrum production initially, which
is a thick, yellowish fluid that is rich in antibodies. Full milk production, however,
generally begins 3 to 5 days after delivery, as hormonal changes stimulate the
production of milk.
5. Question:
A client at 32 weeks gestation presents with sudden-onset abdominal pain, vaginal
bleeding, and a rigid abdomen. Which condition does this most likely indicate?
a) Placenta previa
b) Placental abruption
c) Ectopic pregnancy
d) Preterm labor
Answer:
b) Placental abruption
Rationale:
Placental abruption is the premature separation of the placenta from the uterine
wall, typically presenting with sudden abdominal pain, vaginal bleeding, and a
rigid, board-like abdomen. This is a medical emergency and requires immediate
intervention to stabilize the mother and fetus.
6. Question:
A nurse is preparing a teaching plan for a pregnant woman who is in her first
trimester. Which of the following instructions should be included regarding
nutrition?
a) "Increase your intake of high-protein foods to support fetal development."
b) "You should consume 500 additional calories per day during the first trimester."
, c) "Avoid dairy products, as they can increase the risk of gestational diabetes."
d) "Take prenatal vitamins that include folic acid to prevent neural tube defects."
Answer:
d) "Take prenatal vitamins that include folic acid to prevent neural tube
defects."
Rationale:
During the first trimester, the most important nutritional consideration is ensuring
adequate intake of folic acid, which helps prevent neural tube defects. The
increased caloric intake is typically recommended during the second and third
trimesters, not the first. Additionally, dairy is generally encouraged for its calcium
content unless contraindicated.
7. Question:
A nurse is caring for a client who is 24 hours postpartum and is experiencing a
fever of 101°F (38.3°C). The nurse suspects a postpartum infection. Which of the
following interventions should be a priority?
a) Administering a prescribed antipyretic
b) Performing a breast examination for signs of mastitis
c) Monitoring for signs of deep vein thrombosis (DVT)
d) Encouraging early ambulation
Answer:
b) Performing a breast examination for signs of mastitis
Rationale:
A fever in the early postpartum period could indicate an infection such as mastitis
(infection of the breast tissue), urinary tract infection, or endometritis. Mastitis
commonly presents with localized breast pain, redness, and flu-like symptoms. A
breast exam is a priority to rule out this infection, and the nurse should also assess
other potential infection sources.
8. Question:
