Maternity Nursing – Full Question & Answer Review

OB / Maternity Nursing – Full Question & Answer Review Questions are written in full. Correct answers are listed with brief clinical rationale only when needed. 1. Fentanyl administration during labor A nurse is caring for a client in labor who received fentanyl 20 minutes ago. Vital signs show RR 10/min, HR 62/min. Which agent should be administered? Answer: Naloxone Rationale: Naloxone reverses opioid■induced respiratory depression. 2. Probable signs of pregnancy Gentle tap on cervix causes rebound of fetus. Interpretation? Answer: Ballottement Rationale: Ballottement is a probable sign of pregnancy. 3. Type 1 diabetes & pregnancy complications Select all that apply. Answer: Hypertension, Polyhydramnios, Increased risk of miscarriage 4. Late decelerations Late decels noted after contractions. Priority intervention? Answer: Place client in left side■lying position 5. No prenatal care at 28 weeks Priority nursing action? Answer: Assess medical, obstetric, violence, and substance■use history 6. Glucose challenge screening Teaching includes which information? Answer: Screening takes 1 hour; Normal result <140 mg/dL 7. Naegele’s rule LMP April 10. EDD? Answer: January 17 8. True labor manifestations Select all that apply. Answer: Increasing contraction intensity; Cervical dilation 9. Reassuring fetal heart tracing Baseline 150, moderate variability, accelerations present. Action? Answer: Continue monitoring 10. Morning sickness vs hyperemesis Normal vitals, morning vomiting, normal urine color. Answer: Morning sickness 11. Apgar 4 at 1 min, 6 at 5 min Priority nursing action? Answer: Continue monitoring and prepare for possible resuscitation 12. Diabetes education Correct teaching statement? Answer: Type 1 diabetes carries the highest maternal■fetal risk 13. Labor stage interpretation 8 cm dilated, irritable, strong contractions. Answer: Late active phase of first stage 14. Graves’ disease in pregnancy Appropriate nursing action? Answer: Educate about Graves’ disease and medication adherence 15. Pregnancy risk factors Select all that apply. Answer: High BMI; Chronic hypertension 16. Risk for preeclampsia Which findings support risk? Answer: BMI 42; Gestational diabetes; Chronic hypertension 17. Oxytocin complication Client at highest risk for uterine tachysystole is evidenced by what? Answer: Oxytocin infusion 18. Indicated vs contraindicated interventions Indicated: BP q5 min; FHR & contractions q15 min; Foley catheter Contraindicated: IV fluids 2000 mL/8 hr 19. Normal labor progression signs Answer: Rectal pressure; Strong contractions; Reassuring FHR 20. Second■trimester BP decrease Answer: Normal progesterone■related vasodilation 21. Anxiety during labor Answer: Support from care partner 22. Eclampsia complications Answer: Aspiration pneumonia; Cerebral edema; Fetal hypoxia; Cortical blindness 23. Late deceleration intervention Answer: Side■lying position 24. Preeclampsia symptoms Answer: Notify provider immediately 25. Fetal station Presenting part 2 cm above ischial spines. Answer: −2 station 26. PPROM risk factor Answer: Polyhydramnios 27. Severe preeclampsia neurologic cause Answer: Cerebral autoregulation dysfunction 28. Severe BP with symptoms Answer: Preeclampsia with severe features 29. LMWH education Answer: Weekly NSTs starting at 36 weeks 30. Hypothyroidism cause Answer: Graves’ disease 31. Early second■trimester miscarriage Answer: Misoprostol 32. FHR category Answer: Category II 33. Epidural contraindication Answer: Platelets 75,000/µL 34. 9■cm dilation triage action Answer: Move client to labor room and admit 35. Newborn opioid exposure care Answer: Monitor respirations; feeding; tone; Apgar scores 36. Placental abruption risk Answer: Polyhydramnios 37. Cultural pain management Answer: Collaborate to safely incorporate practices 38. Normal pregnancy changes Answer: Linea nigra; melasma; diastasis recti; lumbar lordosis 39. Prenatal labs (HBsAg+) Answer: Assess for preeclampsia due to proteinuria 40. Shoulder presentation Answer: Prepare for cesarean delivery 41. Initial prenatal visit actions Answer: Calculate EDD; obtain history; urine test; schedule labs