NGN NCLEX-RN
MATERNAL- CHILD HEALTH
Exam Elaborations Questions &
Answers
2026
, A laboring patient at 38 weeks gestation is receiving a Magnesium Sulfate infusion for
severe pre-eclampsia. During an assessment, the nurse finds the patient has a respiratory
rate of 10 breaths per minute, absent deep tendon reflexes, and a urine output of 20 mL
over the last hour. What is the immediate priority nursing action? A) Continue the infusion
and notify the provider, B) Administer a fluid bolus to increase urine output, C)
Discontinue the Magnesium Sulfate infusion, D) Prepare for an emergency Cesarean
section.
Answer: C. Rationale: These are definitive signs of Magnesium Sulfate toxicity. The first
and most critical action is to stop the causative agent before administering the antagonist,
Calcium Gluconate.
The laboratory findings of Low Platelets, Elevated Liver Enzymes, and Hemolysis in a
pregnant patient with hypertension are the diagnostic hallmarks of ____ Syndrome.
Answer: HELLP. Rationale: HELLP syndrome is a life-threatening variant of pre-
eclampsia. Hemolysis leads to anemia, while elevated liver enzymes and low platelets
indicate hepatic involvement and coagulopathy.
True or False: In a patient diagnosed with Placenta Previa, the nurse should expect to find
painful, board-like abdominal rigidity and dark red vaginal bleeding.
Answer: False. Rationale: Painful, rigid abdomen and dark red bleeding are classic signs of
Abruptio Placentae. Placenta Previa is characterized by painless, bright red vaginal
bleeding in the third trimester.
A patient at 32 weeks gestation presents with preterm premature rupture of membranes.
The provider orders Betamethasone (Celestone) 12 mg IM. What is the primary purpose of
this medication in this clinical scenario? A) To stop uterine contractions, B) To prevent
neonatal Group B Strep infection, C) To promote fetal lung maturity by increasing
surfactant production, D) To increase maternal blood pressure.
Answer: C. Rationale: Antenatal corticosteroids like Betamethasone are given to women at
risk for preterm delivery to accelerate fetal lung development and reduce the risk of
Respiratory Distress Syndrome.
A postpartum patient is experiencing significant vaginal bleeding after delivering a 10 lb
infant. The nurse notes the fundus is boggy and displaced to the right. The first nursing
intervention should be to ____.
Answer: Assist the patient to the bathroom to void (or catheterize). Rationale: A displaced
fundus usually indicates a distended bladder, which prevents the uterus from contracting
effectively. Emptying the bladder allows the uterus to return to the midline and firm up.
True or False: Administration of Rho(D) Immune Globulin (RhoGAM) is required for an
Rh-negative mother if her newborn is also Rh-negative.
Answer: False. Rationale: RhoGAM is only necessary if the newborn is Rh-positive, to
prevent the mother from forming antibodies that could attack future Rh-positive
pregnancies.
The nurse is monitoring a fetal heart rate tracing and observes a pattern of gradual
decelerations that begin after the peak of the contraction and return to baseline after the
contraction has ended. This pattern is known as ____ decelerations.
Answer: Late. Rationale: Late decelerations indicate uteroplacental insufficiency and are
2
MATERNAL- CHILD HEALTH
Exam Elaborations Questions &
Answers
2026
, A laboring patient at 38 weeks gestation is receiving a Magnesium Sulfate infusion for
severe pre-eclampsia. During an assessment, the nurse finds the patient has a respiratory
rate of 10 breaths per minute, absent deep tendon reflexes, and a urine output of 20 mL
over the last hour. What is the immediate priority nursing action? A) Continue the infusion
and notify the provider, B) Administer a fluid bolus to increase urine output, C)
Discontinue the Magnesium Sulfate infusion, D) Prepare for an emergency Cesarean
section.
Answer: C. Rationale: These are definitive signs of Magnesium Sulfate toxicity. The first
and most critical action is to stop the causative agent before administering the antagonist,
Calcium Gluconate.
The laboratory findings of Low Platelets, Elevated Liver Enzymes, and Hemolysis in a
pregnant patient with hypertension are the diagnostic hallmarks of ____ Syndrome.
Answer: HELLP. Rationale: HELLP syndrome is a life-threatening variant of pre-
eclampsia. Hemolysis leads to anemia, while elevated liver enzymes and low platelets
indicate hepatic involvement and coagulopathy.
True or False: In a patient diagnosed with Placenta Previa, the nurse should expect to find
painful, board-like abdominal rigidity and dark red vaginal bleeding.
Answer: False. Rationale: Painful, rigid abdomen and dark red bleeding are classic signs of
Abruptio Placentae. Placenta Previa is characterized by painless, bright red vaginal
bleeding in the third trimester.
A patient at 32 weeks gestation presents with preterm premature rupture of membranes.
The provider orders Betamethasone (Celestone) 12 mg IM. What is the primary purpose of
this medication in this clinical scenario? A) To stop uterine contractions, B) To prevent
neonatal Group B Strep infection, C) To promote fetal lung maturity by increasing
surfactant production, D) To increase maternal blood pressure.
Answer: C. Rationale: Antenatal corticosteroids like Betamethasone are given to women at
risk for preterm delivery to accelerate fetal lung development and reduce the risk of
Respiratory Distress Syndrome.
A postpartum patient is experiencing significant vaginal bleeding after delivering a 10 lb
infant. The nurse notes the fundus is boggy and displaced to the right. The first nursing
intervention should be to ____.
Answer: Assist the patient to the bathroom to void (or catheterize). Rationale: A displaced
fundus usually indicates a distended bladder, which prevents the uterus from contracting
effectively. Emptying the bladder allows the uterus to return to the midline and firm up.
True or False: Administration of Rho(D) Immune Globulin (RhoGAM) is required for an
Rh-negative mother if her newborn is also Rh-negative.
Answer: False. Rationale: RhoGAM is only necessary if the newborn is Rh-positive, to
prevent the mother from forming antibodies that could attack future Rh-positive
pregnancies.
The nurse is monitoring a fetal heart rate tracing and observes a pattern of gradual
decelerations that begin after the peak of the contraction and return to baseline after the
contraction has ended. This pattern is known as ____ decelerations.
Answer: Late. Rationale: Late decelerations indicate uteroplacental insufficiency and are
2
