NUR 254 Exam 2 – Maternal and Pediatric
Nursing (Intrapartum, Postpartum, and
Newborn) Questions And Well Graded Solutions
With Rationales Updated 2026-2027
1. A client in active labor is 6 cm dilated. The nurse notes contractions every 2-3
minutes lasting 60 seconds. What phase of labor is the client in?
A. Latent phase
B. Active phase
C. Transition phase
D. Second stage
Answer in italic bold: B. Active phase.
Rationale in italic: The active phase of labor is characterized by cervical dilation
from 4-7 cm with regular, strong contractions. The latent phase is 0-3 cm,
transition is 8-10 cm, and the second stage begins at full dilation .
2. A client at 39 weeks gestation is in the transition phase of labor. Which behavior
would the nurse expect?
A. Calm and cooperative
B. Irritability and feeling out of control
C. Sleepy and relaxed
D. Eager to push
Answer in italic bold: B. Irritability and feeling out of control.
Rationale in italic: The transition phase (8-10 cm) is the most intense phase of
labor. Clients often experience irritability, restlessness, and a feeling of being
out of control due to the rapid cervical change and intense contractions .
3. A nurse is assessing a client in labor and notes the cervix is 9 cm dilated. The client
reports an urge to push. What should the nurse instruct the client to do?
A. Push with the urge
B. Pant through the urge to prevent pushing
C. Hold her breath and bear down
D. Begin pushing with contractions
Answer in italic bold: B. Pant through the urge to prevent pushing.
Rationale in italic: Pushing before complete cervical dilation can cause cervical
edema and trauma. The client should be instructed to pant through the urge
until complete dilation (10 cm) is achieved .
4. A client in labor has a fetal heart rate tracing with variable decelerations. What is the
priority nursing action?
A. Administer oxygen
, B. Position the client on her left side
C. Perform amnioinfusion
D. Notify the provider
Answer in italic bold: B. Position the client on her left side.
Rationale in italic: Variable decelerations are caused by umbilical cord
compression. The initial intervention is to reposition the client to relieve
pressure on the cord. Left lateral position improves uterine perfusion .
5. A client at 40 weeks gestation is in labor. The nurse notes late decelerations on the
fetal monitor. What is the most likely cause?
A. Head compression
B. Cord compression
C. Uteroplacental insufficiency
D. Maternal hypotension
Answer in italic bold: C. Uteroplacental insufficiency.
Rationale in italic: Late decelerations are caused by uteroplacental
insufficiency, resulting in fetal hypoxia. They are characterized by a gradual
decrease in FHR that begins after the contraction peaks and returns to baseline
after the contraction ends .
6. A client is experiencing late decelerations. What is the priority nursing intervention?
A. Position the client on her left side
B. Administer oxygen at 10 L/min via face mask
C. Increase IV fluids
D. Notify the provider
Answer in italic bold: A. Position the client on her left side.
Rationale in italic: The first-line intervention for late decelerations is to position
the client on her left side to improve placental perfusion. Oxygen and IV fluids
are secondary interventions, and the provider is notified if decelerations persist .
7. A client in labor has an epidural in place. What is the priority assessment after
placement?
A. Maternal temperature
B. Fetal heart rate
C. Maternal blood pressure
D. Urinary output
Answer in italic bold: C. Maternal blood pressure.
Rationale in italic: The most common complication of epidural anesthesia is
maternal hypotension due to sympathetic blockade. Hypotension can lead to
decreased placental perfusion and fetal compromise, making blood pressure the
priority assessment .
8. A client who received an epidural 15 minutes ago now has a blood pressure of 88/56
mmHg. What is the priority nursing action?
A. Administer ephedrine
B. Position client in left lateral tilt position
C. Increase the rate of IV fluids
, D. Notify the anesthesiologist
Answer in italic bold: B. Position client in left lateral tilt position.
Rationale in italic: The initial intervention for hypotension following epidural
placement is to position the client in a left lateral tilt to displace the gravid
uterus off the vena cava, improving venous return and blood pressure .
9. A client at 38 weeks gestation is receiving oxytocin for induction of labor. The nurse
notes uterine contractions lasting 100 seconds with a frequency of every 1.5 minutes.
What is the priority action?
A. Continue the infusion as ordered
B. Increase the oxytocin infusion rate
C. Stop the oxytocin infusion
D. Position the client on her right side
Answer in italic bold: C. Stop the oxytocin infusion.
Rationale in italic: Uterine contractions lasting >90 seconds or occurring more
frequently than every 2 minutes indicate uterine hyperstimulation. The oxytocin
infusion must be stopped immediately to prevent uterine rupture or fetal
distress .
10. A client at 39 weeks gestation is in the second stage of labor for 2 hours without
progress. What is this called?
A. Prolonged latent phase
B. Arrest of active phase
C. Prolonged second stage
D. Shoulder dystocia
Answer in italic bold: C. Prolonged second stage.
Rationale in italic: The second stage of labor is considered prolonged if it
exceeds 2 hours in a nulliparous client or 1 hour in a multiparous client without
regional anesthesia, or 3 hours with regional anesthesia .
11. A client with a prolonged second stage is at risk for which fetal complication?
A. Fetal hypoxia and acidosis
B. Fetal macrosomia
C. Fetal growth restriction
D. Fetal anomalies
Answer in italic bold: A. Fetal hypoxia and acidosis.
Rationale in italic: Prolonged second stage can lead to fetal hypoxia and
acidosis due to prolonged head compression and decreased placental perfusion .
12. A client at 40 weeks gestation is in the transition phase. The nurse notes the client is
shaking and nauseated. What is the most appropriate nursing response?
A. "You should try to stop shaking."
B. "This is a normal response to intense labor."
C. "I will call the provider for medication."
D. "You must be cold; I'll get a blanket."
*Answer in italic bold: B. "This is a normal response to intense labor." *
Rationale in italic: Shaking and nausea are common during the transition phase
, due to hormonal changes and the intense physical exertion of labor. Reassuring
the client is appropriate .
13. A nurse is assessing fetal heart rate and notes a baseline of 150 bpm with moderate
variability and accelerations. What is the interpretation?
A. Category I tracing (normal)
B. Category II tracing (indeterminate)
C. Category III tracing (abnormal)
D. Fetal distress
*Answer in italic bold: A. Category I tracing (normal). *
Rationale in italic: A Category I tracing is normal and includes a baseline of
110-160 bpm, moderate variability, and accelerations. No intervention is
needed .
14. A client has a fetal heart rate tracing with absent variability and recurrent late
decelerations. This is a Category III tracing. What is the priority action?
A. Continue monitoring
B. Administer oxygen and reposition
C. Prepare for immediate delivery
D. Perform a scalp stimulation
*Answer in italic bold: C. Prepare for immediate delivery. *
Rationale in italic: Category III tracings indicate fetal acidosis and require
prompt evaluation and immediate delivery to prevent fetal harm .
15. A client at 37 weeks gestation is diagnosed with preeclampsia. Which symptom
requires immediate reporting?
A. Headache
B. Epigastric pain
C. Edema
D. Nausea
*Answer in italic bold: B. Epigastric pain. *
Rationale in italic: Epigastric pain is a sign of hepatic involvement in
preeclampsia and may indicate HELLP syndrome. This requires immediate
notification and possible delivery .
16. A client with preeclampsia is receiving magnesium sulfate. The nurse should monitor
for which sign of toxicity?
A. Urinary output > 30 mL/hr
B. Respiratory rate of 12 breaths/min
C. Diminished deep tendon reflexes
D. Serum magnesium level of 5 mEq/L
*Answer in italic bold: C. Diminished deep tendon reflexes. *
Rationale in italic: Diminished or absent deep tendon reflexes indicate
magnesium toxicity. The normal therapeutic range is 4-7 mEq/L. Toxicity also
presents with respiratory depression (<12 breaths/min) and oliguria (<30
mL/hr) .
Nursing (Intrapartum, Postpartum, and
Newborn) Questions And Well Graded Solutions
With Rationales Updated 2026-2027
1. A client in active labor is 6 cm dilated. The nurse notes contractions every 2-3
minutes lasting 60 seconds. What phase of labor is the client in?
A. Latent phase
B. Active phase
C. Transition phase
D. Second stage
Answer in italic bold: B. Active phase.
Rationale in italic: The active phase of labor is characterized by cervical dilation
from 4-7 cm with regular, strong contractions. The latent phase is 0-3 cm,
transition is 8-10 cm, and the second stage begins at full dilation .
2. A client at 39 weeks gestation is in the transition phase of labor. Which behavior
would the nurse expect?
A. Calm and cooperative
B. Irritability and feeling out of control
C. Sleepy and relaxed
D. Eager to push
Answer in italic bold: B. Irritability and feeling out of control.
Rationale in italic: The transition phase (8-10 cm) is the most intense phase of
labor. Clients often experience irritability, restlessness, and a feeling of being
out of control due to the rapid cervical change and intense contractions .
3. A nurse is assessing a client in labor and notes the cervix is 9 cm dilated. The client
reports an urge to push. What should the nurse instruct the client to do?
A. Push with the urge
B. Pant through the urge to prevent pushing
C. Hold her breath and bear down
D. Begin pushing with contractions
Answer in italic bold: B. Pant through the urge to prevent pushing.
Rationale in italic: Pushing before complete cervical dilation can cause cervical
edema and trauma. The client should be instructed to pant through the urge
until complete dilation (10 cm) is achieved .
4. A client in labor has a fetal heart rate tracing with variable decelerations. What is the
priority nursing action?
A. Administer oxygen
, B. Position the client on her left side
C. Perform amnioinfusion
D. Notify the provider
Answer in italic bold: B. Position the client on her left side.
Rationale in italic: Variable decelerations are caused by umbilical cord
compression. The initial intervention is to reposition the client to relieve
pressure on the cord. Left lateral position improves uterine perfusion .
5. A client at 40 weeks gestation is in labor. The nurse notes late decelerations on the
fetal monitor. What is the most likely cause?
A. Head compression
B. Cord compression
C. Uteroplacental insufficiency
D. Maternal hypotension
Answer in italic bold: C. Uteroplacental insufficiency.
Rationale in italic: Late decelerations are caused by uteroplacental
insufficiency, resulting in fetal hypoxia. They are characterized by a gradual
decrease in FHR that begins after the contraction peaks and returns to baseline
after the contraction ends .
6. A client is experiencing late decelerations. What is the priority nursing intervention?
A. Position the client on her left side
B. Administer oxygen at 10 L/min via face mask
C. Increase IV fluids
D. Notify the provider
Answer in italic bold: A. Position the client on her left side.
Rationale in italic: The first-line intervention for late decelerations is to position
the client on her left side to improve placental perfusion. Oxygen and IV fluids
are secondary interventions, and the provider is notified if decelerations persist .
7. A client in labor has an epidural in place. What is the priority assessment after
placement?
A. Maternal temperature
B. Fetal heart rate
C. Maternal blood pressure
D. Urinary output
Answer in italic bold: C. Maternal blood pressure.
Rationale in italic: The most common complication of epidural anesthesia is
maternal hypotension due to sympathetic blockade. Hypotension can lead to
decreased placental perfusion and fetal compromise, making blood pressure the
priority assessment .
8. A client who received an epidural 15 minutes ago now has a blood pressure of 88/56
mmHg. What is the priority nursing action?
A. Administer ephedrine
B. Position client in left lateral tilt position
C. Increase the rate of IV fluids
, D. Notify the anesthesiologist
Answer in italic bold: B. Position client in left lateral tilt position.
Rationale in italic: The initial intervention for hypotension following epidural
placement is to position the client in a left lateral tilt to displace the gravid
uterus off the vena cava, improving venous return and blood pressure .
9. A client at 38 weeks gestation is receiving oxytocin for induction of labor. The nurse
notes uterine contractions lasting 100 seconds with a frequency of every 1.5 minutes.
What is the priority action?
A. Continue the infusion as ordered
B. Increase the oxytocin infusion rate
C. Stop the oxytocin infusion
D. Position the client on her right side
Answer in italic bold: C. Stop the oxytocin infusion.
Rationale in italic: Uterine contractions lasting >90 seconds or occurring more
frequently than every 2 minutes indicate uterine hyperstimulation. The oxytocin
infusion must be stopped immediately to prevent uterine rupture or fetal
distress .
10. A client at 39 weeks gestation is in the second stage of labor for 2 hours without
progress. What is this called?
A. Prolonged latent phase
B. Arrest of active phase
C. Prolonged second stage
D. Shoulder dystocia
Answer in italic bold: C. Prolonged second stage.
Rationale in italic: The second stage of labor is considered prolonged if it
exceeds 2 hours in a nulliparous client or 1 hour in a multiparous client without
regional anesthesia, or 3 hours with regional anesthesia .
11. A client with a prolonged second stage is at risk for which fetal complication?
A. Fetal hypoxia and acidosis
B. Fetal macrosomia
C. Fetal growth restriction
D. Fetal anomalies
Answer in italic bold: A. Fetal hypoxia and acidosis.
Rationale in italic: Prolonged second stage can lead to fetal hypoxia and
acidosis due to prolonged head compression and decreased placental perfusion .
12. A client at 40 weeks gestation is in the transition phase. The nurse notes the client is
shaking and nauseated. What is the most appropriate nursing response?
A. "You should try to stop shaking."
B. "This is a normal response to intense labor."
C. "I will call the provider for medication."
D. "You must be cold; I'll get a blanket."
*Answer in italic bold: B. "This is a normal response to intense labor." *
Rationale in italic: Shaking and nausea are common during the transition phase
, due to hormonal changes and the intense physical exertion of labor. Reassuring
the client is appropriate .
13. A nurse is assessing fetal heart rate and notes a baseline of 150 bpm with moderate
variability and accelerations. What is the interpretation?
A. Category I tracing (normal)
B. Category II tracing (indeterminate)
C. Category III tracing (abnormal)
D. Fetal distress
*Answer in italic bold: A. Category I tracing (normal). *
Rationale in italic: A Category I tracing is normal and includes a baseline of
110-160 bpm, moderate variability, and accelerations. No intervention is
needed .
14. A client has a fetal heart rate tracing with absent variability and recurrent late
decelerations. This is a Category III tracing. What is the priority action?
A. Continue monitoring
B. Administer oxygen and reposition
C. Prepare for immediate delivery
D. Perform a scalp stimulation
*Answer in italic bold: C. Prepare for immediate delivery. *
Rationale in italic: Category III tracings indicate fetal acidosis and require
prompt evaluation and immediate delivery to prevent fetal harm .
15. A client at 37 weeks gestation is diagnosed with preeclampsia. Which symptom
requires immediate reporting?
A. Headache
B. Epigastric pain
C. Edema
D. Nausea
*Answer in italic bold: B. Epigastric pain. *
Rationale in italic: Epigastric pain is a sign of hepatic involvement in
preeclampsia and may indicate HELLP syndrome. This requires immediate
notification and possible delivery .
16. A client with preeclampsia is receiving magnesium sulfate. The nurse should monitor
for which sign of toxicity?
A. Urinary output > 30 mL/hr
B. Respiratory rate of 12 breaths/min
C. Diminished deep tendon reflexes
D. Serum magnesium level of 5 mEq/L
*Answer in italic bold: C. Diminished deep tendon reflexes. *
Rationale in italic: Diminished or absent deep tendon reflexes indicate
magnesium toxicity. The normal therapeutic range is 4-7 mEq/L. Toxicity also
presents with respiratory depression (<12 breaths/min) and oliguria (<30
mL/hr) .
