NURS 203 | NURS 203 Maternity Exam 2 Version 1 |
Questions with Correct Answers and Expert
Explanation for Each Question | Saint Paul’s School
of Nursing
1. A nurse is caring for a client with preeclampsia receiving magnesium sulfate. Which
finding should the nurse report to the provider immediately?
A. A respiratory rate of 10/min
B. Deep tendon reflexes of 2+
C. Urinary output of 40 mL/hr
D. Fetal heart rate of 140/min
Correct Answer: A
Expert Explanation: Magnesium sulfate is used primarily to prevent seizures in
clients with preeclampsia by depressing the central nervous system. A respiratory
rate below 12 breaths per minute is a classic sign of magnesium toxicity. The nurse
must also monitor for the loss of deep tendon reflexes and decreased urinary
output. If toxicity is suspected, the infusion should be halted immediately. Calcium
gluconate must be available at the bedside to reverse these life-threatening effects.
2. A client at 28 weeks of gestation is undergoing a 3-hour glucose tolerance test
(GTT). Which instruction is correct?
A. Fast for 4 hours prior to the start of the test.
,B. Eat a high-carbohydrate diet for 3 days before the test.
C. Avoid caffeine for 24 hours before the test.
D. The test is positive if only one blood sugar level is elevated.
Correct Answer: B
Expert Explanation: Preparation for a 3-hour GTT involves consuming at least 150
grams of carbohydrates for three days prior to testing. The client must fast
overnight for at least 8 to 12 hours before the first blood draw. Caffeine and
smoking should be avoided for 12 hours prior to the procedure to ensure accuracy.
A diagnosis of gestational diabetes is made if two or more blood glucose levels are
elevated. This test is essential for diagnosing metabolic issues that could affect fetal
growth.
3. Which of the following assessments is the priority for a client diagnosed with
abruptio placentae?
A. Assessing fundal height
B. Monitoring for uterine tenderness
C. Continuous fetal heart rate monitoring
D. Evaluating maternal vital signs
Correct Answer: C
,Expert Explanation: Abruptio placentae involves the premature separation of the
placenta from the uterine wall, which compromises fetal oxygenation. Continuous
fetal heart rate monitoring is the priority to detect signs of fetal distress early. While
maternal vital signs are important, the fetus is often affected more rapidly by the
loss of placental attachment. The nurse should also assess for a board-like, rigid
abdomen and vaginal bleeding. Prompt identification and intervention are required
to prevent neonatal morbidity and maternal hemorrhage.
4. A nurse is reviewing lab results for a client with HELLP syndrome. Which finding
should the nurse expect?
A. Elevated hemoglobin
B. Low platelets
C. Decreased liver enzymes
D. Decreased serum creatinine
Correct Answer: B
Expert Explanation: HELLP syndrome is a severe variant of preeclampsia
characterized by hemolysis, elevated liver enzymes, and low platelets. Low platelet
counts, specifically below 100,000/mm3, increase the risk for spontaneous bleeding
and hematomas. Hemolysis is often indicated by abnormal red blood cell
morphology on a smear. Elevated liver enzymes like AST and ALT indicate hepatic
, damage or inflammation. This condition is a medical emergency that usually
necessitates immediate delivery to save the mother.
5. What is the primary purpose of administering betamethasone to a client in preterm
labor?
A. To stop uterine contractions
B. To promote fetal lung maturity
C. To prevent maternal infection
D. To increase maternal blood pressure
Correct Answer: B
Expert Explanation: Betamethasone is a corticosteroid given to pregnant
individuals between 24 and 34 weeks of gestation at risk for preterm birth. Its main
function is to stimulate the production of surfactant in the fetal lungs. This helps
prevent neonatal respiratory distress syndrome, intraventricular hemorrhage, and
necrotizing enterocolitis. Two doses are typically administered intramuscularly 24
hours apart. The maximum benefit of the medication is reached within 24 to 48
hours after the second dose.
6. A nurse identifies late decelerations on the fetal monitor strip. Which action should
the nurse take first?
A. Increase the IV oxytocin rate.
Questions with Correct Answers and Expert
Explanation for Each Question | Saint Paul’s School
of Nursing
1. A nurse is caring for a client with preeclampsia receiving magnesium sulfate. Which
finding should the nurse report to the provider immediately?
A. A respiratory rate of 10/min
B. Deep tendon reflexes of 2+
C. Urinary output of 40 mL/hr
D. Fetal heart rate of 140/min
Correct Answer: A
Expert Explanation: Magnesium sulfate is used primarily to prevent seizures in
clients with preeclampsia by depressing the central nervous system. A respiratory
rate below 12 breaths per minute is a classic sign of magnesium toxicity. The nurse
must also monitor for the loss of deep tendon reflexes and decreased urinary
output. If toxicity is suspected, the infusion should be halted immediately. Calcium
gluconate must be available at the bedside to reverse these life-threatening effects.
2. A client at 28 weeks of gestation is undergoing a 3-hour glucose tolerance test
(GTT). Which instruction is correct?
A. Fast for 4 hours prior to the start of the test.
,B. Eat a high-carbohydrate diet for 3 days before the test.
C. Avoid caffeine for 24 hours before the test.
D. The test is positive if only one blood sugar level is elevated.
Correct Answer: B
Expert Explanation: Preparation for a 3-hour GTT involves consuming at least 150
grams of carbohydrates for three days prior to testing. The client must fast
overnight for at least 8 to 12 hours before the first blood draw. Caffeine and
smoking should be avoided for 12 hours prior to the procedure to ensure accuracy.
A diagnosis of gestational diabetes is made if two or more blood glucose levels are
elevated. This test is essential for diagnosing metabolic issues that could affect fetal
growth.
3. Which of the following assessments is the priority for a client diagnosed with
abruptio placentae?
A. Assessing fundal height
B. Monitoring for uterine tenderness
C. Continuous fetal heart rate monitoring
D. Evaluating maternal vital signs
Correct Answer: C
,Expert Explanation: Abruptio placentae involves the premature separation of the
placenta from the uterine wall, which compromises fetal oxygenation. Continuous
fetal heart rate monitoring is the priority to detect signs of fetal distress early. While
maternal vital signs are important, the fetus is often affected more rapidly by the
loss of placental attachment. The nurse should also assess for a board-like, rigid
abdomen and vaginal bleeding. Prompt identification and intervention are required
to prevent neonatal morbidity and maternal hemorrhage.
4. A nurse is reviewing lab results for a client with HELLP syndrome. Which finding
should the nurse expect?
A. Elevated hemoglobin
B. Low platelets
C. Decreased liver enzymes
D. Decreased serum creatinine
Correct Answer: B
Expert Explanation: HELLP syndrome is a severe variant of preeclampsia
characterized by hemolysis, elevated liver enzymes, and low platelets. Low platelet
counts, specifically below 100,000/mm3, increase the risk for spontaneous bleeding
and hematomas. Hemolysis is often indicated by abnormal red blood cell
morphology on a smear. Elevated liver enzymes like AST and ALT indicate hepatic
, damage or inflammation. This condition is a medical emergency that usually
necessitates immediate delivery to save the mother.
5. What is the primary purpose of administering betamethasone to a client in preterm
labor?
A. To stop uterine contractions
B. To promote fetal lung maturity
C. To prevent maternal infection
D. To increase maternal blood pressure
Correct Answer: B
Expert Explanation: Betamethasone is a corticosteroid given to pregnant
individuals between 24 and 34 weeks of gestation at risk for preterm birth. Its main
function is to stimulate the production of surfactant in the fetal lungs. This helps
prevent neonatal respiratory distress syndrome, intraventricular hemorrhage, and
necrotizing enterocolitis. Two doses are typically administered intramuscularly 24
hours apart. The maximum benefit of the medication is reached within 24 to 48
hours after the second dose.
6. A nurse identifies late decelerations on the fetal monitor strip. Which action should
the nurse take first?
A. Increase the IV oxytocin rate.
