NURS 203 | NURS 203 Maternity Exam 3 Version 2
Questions with Correct Answers and Expert
Explanation for Each Question
1. A nurse is monitoring a fetal heart rate (FHR) tracing and notes moderate variability
with an average baseline of 140 bpm. How should the nurse interpret this finding?
A. An indication of fetal distress requiring immediate delivery.
B. An early sign of fetal hypoxia and acidosis.
C. A normal and reassuring sign of fetal well-being.
D. A result of maternal sedation or fetal sleep cycles.
Correct Answer: C
Expert Explanation: Moderate variability is defined as a fluctuation range of 6 to
25 beats per minute from the baseline. This finding indicates that the fetal central
nervous system is intact and well-oxygenated. It is considered a Category I tracing
which is normal and requires no intervention. The nurse should document this as a
reassuring finding during the intrapartum period. Continued monitoring is
appropriate while labor progresses as expected.
2. Which intervention should the nurse prioritize for a patient experiencing repetitive
late decelerations on the fetal monitor?
A. Increase the rate of the oxytocin (Pitocin) infusion.
,B. Reposition the patient to a lateral side-lying position.
C. Perform a vaginal exam to check for cord prolapse.
D. Request the patient to begin pushing immediately.
Correct Answer: B
Expert Explanation: Late decelerations are caused by uteroplacental insufficiency
and require immediate nursing action. The first step in intrauterine resuscitation is
typically repositioning the mother to her side to improve blood flow. The nurse
should also discontinue any oxytocin infusion that is currently running. Oxygen
administration and increasing IV fluids are additional supportive measures to take.
These steps aim to enhance oxygen delivery to the fetus and resolve the
decelerations.
3. A patient in the transition phase of labor complains of a sudden sharp pain in her
abdomen and the nurse observes a rapid decline in FHR. What is the most likely
complication?
A. Braxton Hicks contractions
B. Placenta previa
C. Normal labor progression
D. Uterine rupture
,Correct Answer: D
Expert Explanation: Uterine rupture is a life-threatening obstetric emergency
characterized by sudden abdominal pain and fetal distress. The loss of fetal station
and cessation of contractions often accompany this event. Patients with a history of
previous cesarean sections are at a higher risk for this complication. The nurse must
immediately notify the surgical team for an emergency cesarean delivery. Stabilizing
the mother with fluids and preparing for surgery are the highest priorities.
4. A nurse identifies variable decelerations on the monitor. What is the physiological
cause of this pattern?
A. Fetal head compression
B. Umbilical cord compression
C. Uteroplacental insufficiency
D. Maternal hypotension
Correct Answer: B
Expert Explanation: Variable decelerations are abrupt decreases in FHR that vary
in duration and timing relative to contractions. They are primarily caused by
umbilical cord compression during labor. The shape of the deceleration often
resembles a ‘U’, ‘V’, or ‘W’ on the monitor strip. Nursing interventions include
, changing the maternal position to relieve pressure on the cord. If the pattern
persists, an amnioinfusion may be ordered to provide a cushion for the cord.
5. During the active phase of labor, the nurse notes early decelerations. What is the
appropriate nursing action?
A. Document the finding and continue to monitor.
B. Administer oxygen at 10 L/min via mask.
C. Prepare the patient for an emergency C-section.
D. Notify the provider of fetal intolerance to labor.
Correct Answer: A
Expert Explanation: Early decelerations are caused by fetal head compression as
the fetus descends into the birth canal. These decelerations mirror the contraction,
starting and ending at the same time. They are considered benign findings and do
not indicate fetal distress or hypoxia. No specific clinical intervention is required
other than standard monitoring of labor progress. The nurse should simply
document the presence of these decelerations in the medical record.
6. A patient is receiving Magnesium Sulfate for preeclampsia. Which assessment
finding would indicate toxicity?
A. Presence of 2+ deep tendon reflexes
B. Urine output of 50 mL per hour
Questions with Correct Answers and Expert
Explanation for Each Question
1. A nurse is monitoring a fetal heart rate (FHR) tracing and notes moderate variability
with an average baseline of 140 bpm. How should the nurse interpret this finding?
A. An indication of fetal distress requiring immediate delivery.
B. An early sign of fetal hypoxia and acidosis.
C. A normal and reassuring sign of fetal well-being.
D. A result of maternal sedation or fetal sleep cycles.
Correct Answer: C
Expert Explanation: Moderate variability is defined as a fluctuation range of 6 to
25 beats per minute from the baseline. This finding indicates that the fetal central
nervous system is intact and well-oxygenated. It is considered a Category I tracing
which is normal and requires no intervention. The nurse should document this as a
reassuring finding during the intrapartum period. Continued monitoring is
appropriate while labor progresses as expected.
2. Which intervention should the nurse prioritize for a patient experiencing repetitive
late decelerations on the fetal monitor?
A. Increase the rate of the oxytocin (Pitocin) infusion.
,B. Reposition the patient to a lateral side-lying position.
C. Perform a vaginal exam to check for cord prolapse.
D. Request the patient to begin pushing immediately.
Correct Answer: B
Expert Explanation: Late decelerations are caused by uteroplacental insufficiency
and require immediate nursing action. The first step in intrauterine resuscitation is
typically repositioning the mother to her side to improve blood flow. The nurse
should also discontinue any oxytocin infusion that is currently running. Oxygen
administration and increasing IV fluids are additional supportive measures to take.
These steps aim to enhance oxygen delivery to the fetus and resolve the
decelerations.
3. A patient in the transition phase of labor complains of a sudden sharp pain in her
abdomen and the nurse observes a rapid decline in FHR. What is the most likely
complication?
A. Braxton Hicks contractions
B. Placenta previa
C. Normal labor progression
D. Uterine rupture
,Correct Answer: D
Expert Explanation: Uterine rupture is a life-threatening obstetric emergency
characterized by sudden abdominal pain and fetal distress. The loss of fetal station
and cessation of contractions often accompany this event. Patients with a history of
previous cesarean sections are at a higher risk for this complication. The nurse must
immediately notify the surgical team for an emergency cesarean delivery. Stabilizing
the mother with fluids and preparing for surgery are the highest priorities.
4. A nurse identifies variable decelerations on the monitor. What is the physiological
cause of this pattern?
A. Fetal head compression
B. Umbilical cord compression
C. Uteroplacental insufficiency
D. Maternal hypotension
Correct Answer: B
Expert Explanation: Variable decelerations are abrupt decreases in FHR that vary
in duration and timing relative to contractions. They are primarily caused by
umbilical cord compression during labor. The shape of the deceleration often
resembles a ‘U’, ‘V’, or ‘W’ on the monitor strip. Nursing interventions include
, changing the maternal position to relieve pressure on the cord. If the pattern
persists, an amnioinfusion may be ordered to provide a cushion for the cord.
5. During the active phase of labor, the nurse notes early decelerations. What is the
appropriate nursing action?
A. Document the finding and continue to monitor.
B. Administer oxygen at 10 L/min via mask.
C. Prepare the patient for an emergency C-section.
D. Notify the provider of fetal intolerance to labor.
Correct Answer: A
Expert Explanation: Early decelerations are caused by fetal head compression as
the fetus descends into the birth canal. These decelerations mirror the contraction,
starting and ending at the same time. They are considered benign findings and do
not indicate fetal distress or hypoxia. No specific clinical intervention is required
other than standard monitoring of labor progress. The nurse should simply
document the presence of these decelerations in the medical record.
6. A patient is receiving Magnesium Sulfate for preeclampsia. Which assessment
finding would indicate toxicity?
A. Presence of 2+ deep tendon reflexes
B. Urine output of 50 mL per hour
