NLE High-Risk Pregnancy & Obstetric Complications Reviewer 2026

Answer: B. Placenta previa

Step 1 — Identify the key clue: the bleeding is PAINLESS and the uterus is SOFT (non-tender). Step 2 — Recall the classic NLE distinction: Placenta previa = PAINLESS bright-red bleeding because the placenta separates from the lower uterine segment as the cervix effaces, without uterine muscle spasm. Step 3 — Eliminate the distractors: Abruptio placentae presents with PAINFUL dark-red bleeding and a RIGID, board-like uterus due to uterine hypertonicity. Threatened abortion occurs before 20 weeks with a closed cervix. Ectopic pregnancy presents before 20 weeks with unilateral pain and signs of shock. Step 4 — Confirm: 34 weeks + painless + soft uterus = placenta previa until proven otherwise. Step 5 — Key nursing rule: NEVER perform a vaginal exam in this scenario — it can perforate the placenta and cause fatal hemorrhage.

Answer: C. Abruptio placentae

Step 1 — Identify the hallmark signs: rigid/board-like uterus (uterine hypertonicity), dark-red bleeding, and pain. Step 2 — Abruptio placentae is the premature separation of a NORMALLY implanted placenta. When the placenta tears away, it triggers severe uterine muscle spasm (hypertonicity), causing that characteristic rigid, wooden-board feel. Step 3 — The bleeding is dark-red because it is often old blood that has collected behind the placenta (concealed hemorrhage). Step 4 — Eliminate distractors: Placenta previa has painless, bright-red bleeding with a SOFT uterus. Threatened abortion occurs before 20 weeks with a closed cervix. Hydatidiform mole presents with prune-juice bleeding and a uterus large for dates. Step 5 — Priority nursing action: treat as an obstetric emergency; monitor for concealed hemorrhage and DIC.

Answer: C. Insert two large-bore IV lines and prepare for emergency surgery

Step 1 — Recognize the clinical picture: unilateral abdominal pain + shoulder-tip pain (Kehr sign from diaphragmatic irritation by intraperitoneal blood) + shock = RUPTURED ectopic pregnancy. Step 2 — A ruptured ectopic is a SURGICAL EMERGENCY with massive internal bleeding. The priority is to restore circulation and stop the bleeding operatively (salpingostomy or salpingectomy). Step 3 — Two large-bore IV lines allow rapid fluid and blood product replacement to treat hypovolemic shock. Step 4 — Eliminate distractors: D&C is for uterine contents, not a ruptured tube. Methotrexate is ONLY for UNRUPTURED small ectopics — giving it in rupture delays life-saving surgery. Bed rest is inappropriate when the patient is in shock. Step 5 — Also administer oxygen and monitor vital signs and urine output continuously.

Answer: B. Within 72 hours after delivery

Step 1 — Understand the purpose: RhoGAM provides passive anti-D antibodies that destroy fetal Rh-positive red blood cells before the mother's immune system can form her own antibodies (sensitization). Step 2 — The postpartum dose must be given WITHIN 72 HOURS of delivery to be effective, because fetal cells entering maternal circulation during delivery are destroyed before the immune response is mounted. Step 3 — The standard dose is 300 mcg IM. Step 4 — Eliminate distractors: 24 hours is acceptable timing but the defining window is 72 hours (3 days). Waiting 7 days is too late — sensitization may already have occurred. The antenatal dose at 28 weeks is separate and does NOT eliminate the need for the postpartum dose. Step 5 — Also remember: a 50-mcg microdose is used for first-trimester events (before 13 weeks).

Answer: C. Threatened abortion

Step 1 — The key assessment findings are: SLIGHT bleeding + MILD cramping + CLOSED cervix + VIABLE fetus. This triad defines THREATENED abortion. Step 2 — In a threatened abortion, the pregnancy is at risk but may still continue because the cervix is closed and the fetus is alive. Step 3 — Contrast with other types: Inevitable abortion has an OPEN (dilated) cervix and membranes may have ruptured — loss cannot be stopped. Incomplete abortion means some products are expelled and some retained, with heavy bleeding and open cervix. Complete abortion means all products are expelled and symptoms subside. Step 4 — Nursing management for threatened abortion: advise activity restriction, avoid intercourse and strenuous activity, and provide emotional support. Step 5 — Monitor beta-hCG levels and repeat ultrasound to assess pregnancy viability.

Answer: C. Hydatidiform mole

Step 1 — Identify the cluster of clues: (a) snowstorm ultrasound pattern = classic molar appearance from the grape-like vesicles; (b) uterus LARGER than dates; (c) markedly elevated beta-hCG from excessive trophoblastic proliferation; (d) preeclampsia BEFORE 20 weeks — this is pathognomonic because preeclampsia normally occurs after 20 weeks. Step 2 — A hydatidiform mole is abnormal trophoblastic proliferation where chorionic villi degenerate into fluid-filled vesicles. Step 3 — Eliminate distractors: Placenta previa shows painless bleeding, not a snowstorm pattern. Twin gestation can cause a large uterus but not a snowstorm pattern or pre-20-week preeclampsia. Abruptio placentae shows painful bleeding with a rigid uterus. Step 4 — Management: suction curettage, then serial beta-hCG monitoring for 6-12 months. Step 5 — Teach: avoid pregnancy for at least 1 year to allow accurate hCG monitoring for choriocarcinoma.

Answer: B. Performing a vaginal or rectal examination

Step 1 — Painless third-trimester bleeding is placenta previa until proven otherwise. Step 2 — In placenta previa, the placenta lies over or near the internal cervical os. A vaginal or rectal examination can PERFORATE or DISRUPT the placenta, causing catastrophic, potentially fatal hemorrhage. Step 3 — This is therefore an ABSOLUTE contraindication regardless of who orders it. The nurse must question any order for a vaginal exam in this scenario. Step 4 — The safe diagnostic tool is transabdominal ULTRASOUND to confirm placental location. Step 5 — All other options listed are APPROPRIATE priority nursing actions: electronic fetal monitoring tracks fetal wellbeing, IV access prepares for hemorrhage management, and lateral positioning improves uteroplacental perfusion.

Answer: B. Avoid folic acid, alcohol, and prolonged sun exposure

Step 1 — Methotrexate is a FOLIC ACID ANTAGONIST that works by inhibiting DNA synthesis in rapidly dividing trophoblastic cells. Step 2 — Because it blocks folate metabolism, taking FOLIC ACID supplements would counteract the drug's effect and reduce its ability to dissolve the ectopic tissue. This is why folic acid is AVOIDED, not given. Step 3 — ALCOHOL must be avoided because methotrexate is hepatotoxic, and alcohol increases the risk of liver damage. Step 4 — SUN EXPOSURE is avoided because methotrexate causes photosensitivity. Step 5 — Teach the patient to REPORT severe or worsening abdominal pain immediately — this could indicate tubal rupture, which changes management from medical to surgical. Follow-up with declining serial beta-hCG confirms treatment success.

Answer: B. To accelerate fetal lung maturity and reduce the risk of neonatal respiratory distress syndrome

Step 1 — Betamethasone is a CORTICOSTEROID given to the MOTHER when preterm delivery is anticipated before 34 weeks gestation. Step 2 — It crosses the placenta and stimulates the FETAL lungs to produce SURFACTANT earlier than they would naturally. Surfactant is the substance that keeps the alveoli open and prevents them from collapsing with each breath. Step 3 — Without sufficient surfactant, the preterm neonate develops Respiratory Distress Syndrome (RDS) — a leading cause of neonatal mortality. Betamethasone significantly reduces this risk. Step 4 — Dosage: 12 mg IM every 24 hours for 2 doses. Step 5 — Eliminate distractors: Betamethasone does NOT stop contractions (tocolytics like nifedipine do that), does NOT lower blood pressure (antihypertensives do), and is NOT an antibiotic.

Answer: C. Disseminated intravascular coagulation (DIC)

Step 1 — Identify the signs: oozing from IV sites + petechiae + hematuria = bleeding from MULTIPLE sites without obvious injury. This pattern indicates a COAGULATION FAILURE. Step 2 — DIC is a consumptive coagulopathy: massive clotting factors are consumed in widespread clot formation, leaving none available for normal hemostasis. The patient paradoxically BLEEDS because all the clotting factors have been used up. Step 3 — In abruptio placentae, THROMBOPLASTIN released from the damaged placenta triggers the DIC cascade. Step 4 — Nursing monitoring: check PLATELETS (low), FIBRINOGEN (low), PT/aPTT (prolonged), and D-DIMER (elevated). Step 5 — Management: deliver the baby (remove the trigger), and replace blood products — packed red blood cells, fresh frozen plasma (FFP), platelets, and cryoprecipitate as ordered.

Answer: B. Prepare for oxytocin augmentation as ordered

Step 1 — Identify the type of dysfunction: The pattern described — weak, infrequent contractions in the ACTIVE phase — is hypotonic uterine dysfunction. Step 2 — Recall management: Hypotonic dysfunction is managed with OXYTOCIN AUGMENTATION (and possibly amniotomy) once obstruction is ruled out. Step 3 — Eliminate wrong options: Sedation and bed rest are used for HYPERTONIC dysfunction (painful, uncoordinated contractions in the LATENT phase) — not hypotonic. Fundal pressure is contraindicated because it does not correct the underlying problem and can cause fetal harm. Knee-chest position is used for prolapsed cord, not dystocia. Step 4 — Key distinction: Hypotonic → Oxytocin; Hypertonic → Rest and sedation. Getting these two mixed up is a classic NLE trap.

Answer: B. Hypertonic uterine dysfunction

Step 1 — Key features: The question describes contractions that are frequent, painful, and uncoordinated but do NOT dilate the cervix. This is the hallmark of HYPERTONIC uterine dysfunction, occurring in the LATENT phase. Step 2 — Compare with hypotonic: Hypotonic dysfunction has WEAK, INFREQUENT contractions in the ACTIVE phase — the opposite pattern. Step 3 — Eliminate other options: Precipitous labor is VERY RAPID labor (under 3 hours), not slow or unproductive. Uterine rupture presents with sudden sharp pain, cessation of contractions, and signs of shock — much more acute. Step 4 — Management clue: Hypertonic dysfunction is managed with REST, SEDATION, and HYDRATION — NOT oxytocin, which would worsen the already-overactive pattern.