NCLEX-RN Maternal-Newborn Nursing 60 Practice Questions with Answers & Rationales

NCLEX-RN Maternal-Newborn Nursing
60 Practice Questions with Answers & Rationales
| NCLEX-RN Standard | Docsity Study Guide




Question 1: A nurse is caring for a client at 38 weeks’ gestation who reports sudden, painless, bright
red vaginal bleeding. The fetal heart rate is 148 bpm. Which condition does the nurse suspect?

A. Placental abruption
B. Placenta Previa
C. Vasa Previa

D. Uterine rupture

✔ Correct Answer: B. Placenta previa

Rationale: Placenta previa is characterized by sudden, PAINLESS, bright red vaginal bleeding in the third
trimester because the placenta overlies the cervical os. Placental abruption typically presents with painful,
dark bleeding. Uterine rupture presents with sudden, sharp abdominal pain and fetal distress. Vasa previa is
rare and involves fetal vessel rupture.


Question 2: A prim gravida at 39 weeks is in active labor with contractions every 3 minutes. The nurse
notes a prolonged deceleration to 80 bpm lasting 3 minutes. What is the nurse's PRIORITY action?

A. Notify the healthcare provider
B. Reposition the client to the left lateral position

C. Prepare for emergency cesarean section
D. Increase IV fluid rate

✔ Correct Answer: B. Reposition the client to the left lateral position

Rationale: The PRIORITY action for prolonged fetal heart rate deceleration is repositioning to the left lateral
(or other positions) to relieve possible cord compression or aortocaval compression and improve
uteroplacental blood flow. Notifying the provider is the next step after initial interventions. Emergency
cesarean is considered if the deceleration does not resolve.


Question 3: A client at 34 weeks gestation is admitted with a blood pressure of 158/110 mmHg, 3+
proteinuria, and severe headache. Which medication does the nurse anticipate administering FIRST?

, A. Hydralazine IV

B. Magnesium sulfate IV

C. Betamethasone IM

D. Labetalol PO

✔ Correct Answer: B. Magnesium sulfate IV

Rationale: Magnesium sulfate is the drug of choice for seizure prophylaxis in severe preeclampsia and is
administered FIRST to prevent eclampsia. Antihypertensive (hydralazine, labetalol) are given to manage
acute severe hypertension (BP ≥160/110) but seizure prevention takes priority. Betamethasone promotes
fetal lung maturity and is important but is not the first priority.


Question 4: A client who is 28 weeks pregnant is receiving magnesium sulfate for preterm labor.
Which assessment finding requires the nurse to STOP the infusion immediately?

A. Urinary output of 40 mL/hour

B. Respiratory rate of 10 breaths/minute
C. DTRs (deep tendon reflexes) 2+

D. Serum magnesium level of 6 mEq/L

✔ Correct Answer: B. Respiratory rate of 10 breaths/minute

Rationale: A respiratory rate below 12 breaths/minute indicates magnesium toxicity and is a critical finding
requiring immediate cessation of the infusion. Normal therapeutic magnesium levels are 4–7 mEq/L. Loss of
DTRs (absent, not 2+) occurs before respiratory depression. A urine output of 30–60 mL/hour is acceptable
minimum. Calcium gluconate must be kept at bedside as antidote.


Question 5: The nurse is assessing a postpartum client 2 hours after vaginal delivery. The uterine
fundus is firm, at the umbilicus, and displaced to the right. What is the most likely cause?

A. Normal postpartum involution

B. Uterine atony

C. Full bladder

D. Retained placental fragments

✔ Correct Answer: C. Full bladder

Rationale: A uterus displaced to the right of midline is the classic sign of a full bladder. The bladder, when
distended, pushes the uterus to the right. The nurse should assist the client to void or catheterize if unable to
void. Uterine atony presents with a soft, boggy fundus. Retained placental fragments cause late postpartum
hemorrhage (>24 hours after delivery).

, Question 6: A nurse is reviewing laboratory results for a client with severe preeclampsia. Which finding
indicates the development of HELLP syndrome?

A. Platelet count of 180,000/mm³

B. AST of 80 units/L
C. Hemoglobin of 11 g/dL

D. Creatinine of 0.8 mg/dL

✔ Correct Answer: B. AST of 80 units/L

Rationale: HELLP syndrome consists of Hemolysis (H), Elevated Liver enzymes (EL), and Low Platelets
(LP). An AST >70 units/L indicates elevated liver enzymes, consistent with HELLP. Platelets <100,000/mm³
indicate low platelets in HELLP. A hemoglobin of 11 g/dL is only mildly low and does not indicate the
microangiopathic hemolysis of HELLP. Normal creatinine does not support HELLP.


Question 7: A multigravida at 41 weeks gestation has an oxytocin infusion running at 12 mU/min. The
monitor shows contractions every 1.5 minutes, lasting 95 seconds, with late decelerations. What is the
nurse's FIRST action?

A. Decrease the oxytocin to 6 mU/min

B. Discontinue the oxytocin infusion
C. Administer oxygen via face mask at 10 L/min

D. Reposition the client

✔ Correct Answer: B. Discontinue the oxytocin infusion

Rationale: Uterine tachysystole (contractions more frequent than every 2 minutes or lasting more than 90
seconds) combined with late decelerations indicates uteroplacental insufficiency caused by oxytocin. The
FIRST action is to STOP the oxytocin infusion. Then reposition, apply oxygen, and notify the provider. Merely
decreasing the rate is insufficient when late decelerations are present.


Question 8: A nurse is caring for a newborn at 5 minutes of age. Respiratory effort is slow and
irregular; heart rate is 92 bpm; the infant grimaces to stimulation; body is pink but extremities are blue;
and muscle tone is some flexion. What is this infant's Apgar score?

A. 4

B. 5

C. 6

D. 7

✔ Correct Answer: C. 6