NR 465 Exam 3 – Maternal Newborn Nursing V2 Masterpiece
2026–2027 | Complete & Verified Questions and Correct
Answers | Latest Updated Edition | Newest Premium PDF
Available on the Market
1. A nurse is planning care for a newborn who requires phototherapy for
hyperbilirubinemia. Which of the following actions should the nurse include in the plan
of care?
a. Keep the newborn swaddled in two blankets
b. Apply lotion to the newborn's skin every 2 hours
c. Ensure the newborn's eyes are closed before applying the eye shield
d. Position the newborn prone during therapy
-CORRECT ANSWER- c. Ensure the newborn's eyes are closed before applying the eye
shield
Rationale: Eye shields are essential during phototherapy to prevent retinal damage
from the intense blue light. Closing the newborn's eyes before applying the shield helps
protect the cornea from direct irritation or injury from the shield itself. Additionally,
keeping the eyes closed reduces the risk of corneal abrasions and ensures that the eye
shield fits properly without causing discomfort. The nurse should also ensure the shield is
secured but not too tight, and remove it during feeding times to allow for eye contact and
assessment.
2. A nurse is caring for a client at 34 weeks gestation who has a prescription for terbutaline
for preterm labor. Which of the following statements by the patient is the priority?
a. "I have a mild headache"
b. "My hands shake a little"
c. "My heart feels as if it is racing"
d. "I feel more tired than usual"
-CORRECT ANSWER- c. "My heart feels as if it is racing"
*Rationale: Terbutaline is a beta-adrenergic agonist that stimulates beta-2 receptors in
the uterus to relax smooth muscle, but it also affects beta-1 receptors in the heart, leading
to tachycardia and palpitations. A racing heart sensation indicates significant cardiac
stimulation, which can progress to more serious complications such as pulmonary edema,
myocardial ischemia, or dysrhythmias. This finding is the priority because it directly
signals potential cardiovascular compromise. While tremors and headache are common
side effects, they are less immediately life-threatening than tachycardia.*
3. A nurse is planning care for a client who is pregnant and is Rh-negative. In which of the
following situations should the nurse administer Rh(D) Immune Globulin?
a. Before chorionic villus sampling
b. Only after delivery of an Rh-positive infant
, c. At 28 weeks of gestation
d. After an uncomplicated first trimester
-CORRECT ANSWER- c. At 28 weeks of gestation
*Rationale: Rh(D) Immune Globulin is given at 28 weeks of gestation as routine
antepartum prophylaxis to prevent Rh sensitization in an Rh-negative mother carrying an
Rh-positive fetus. At this gestational age, fetomaternal hemorrhage becomes more likely
due to normal placental changes, and even small amounts of fetal blood entering the
maternal circulation can trigger antibody formation. Preventing sensitization during
pregnancy is critical because antibodies formed now could affect future pregnancies,
causing hemolytic disease of the newborn. The 28-week dose is standard along with a
postpartum dose if the infant is Rh-positive.*
4. A nurse is caring for a client who is at 39 weeks of gestation and is in active labor. Which
of the following actions should the nurse include in the plan of care?
a. Administer analgesics as soon as the client requests them
b. Check the cervix prior to analgesic administration
c. Give oral fluids liberally throughout labor
d. Apply warm compresses to the perineum only after delivery
-CORRECT ANSWER- b. Check the cervix prior to analgesic administration
Rationale: Before administering systemic analgesics or epidural anesthesia, the
nurse must perform a cervical exam to determine the stage and progress of labor. If labor
is too advanced (typically 8 cm or more), administering analgesics can lead to neonatal
respiratory depression if delivery occurs soon after. Additionally, giving pain medication
too close to delivery may interfere with the mother's ability to push effectively. Cervical
assessment ensures that the timing of analgesia is safe for both mother and fetus, and it
also helps prevent unintended delivery of a newborn affected by the medication.
5. A nurse is planning care for a client who is at 35 weeks of gestation. Which of the
following lab tests should the nurse obtain?
a. Rubella titer
b. Group B streptococcus Beta-hemolytic (GBS)
c. Hemoglobin A1c
d. Thyroid stimulating hormone
-CORRECT ANSWER- b. Group B streptococcus Beta-hemolytic (GBS)
Rationale: The Centers for Disease Control and Prevention recommends universal
GBS screening for all pregnant women at 35 to 37 weeks of gestation. GBS is a leading
cause of neonatal sepsis, pneumonia, and meningitis. A positive result requires
intrapartum antibiotic prophylaxis to reduce vertical transmission during delivery.
Screening earlier may miss colonization that occurs later in pregnancy, while screening
after 37 weeks may not leave enough time to obtain results before delivery. Rubella titer
is typically done early in pregnancy, while Hgb A1c is for diabetic clients and TSH is for
thyroid disorders.
,6. A nurse is caring for a newborn whose mother received magnesium sulfate to treat
preterm labor. Which of the following clinical manifestations in the newborn indicates
toxicity due to the magnesium sulfate therapy?
a. Hyperreflexia
b. Respiratory depression
c. Excessive crying
d. Tachycardia
-CORRECT ANSWER- b. Respiratory depression
Rationale: Magnesium sulfate readily crosses the placenta and can cause neonatal
magnesium toxicity, especially if maternal levels are high or if the infant is premature.
The most serious and life-threatening sign of toxicity is respiratory depression, which
occurs because magnesium acts as a central nervous system depressant and can weaken
the respiratory muscles. Other signs of hypermagnesemia in the newborn include
hypotonia, lethargy, poor sucking reflex, and hyporeflexia. Hyperreflexia and excessive
crying are not associated with magnesium toxicity; they are more consistent with
neonatal abstinence syndrome or other conditions.
7. A nurse is caring for a client who is in labor and has an epidural for pain relief. Which of
the following is a complication from the epidural block?
a. Hypertension
b. Tachycardia
c. Hypotension
d. Hyperthermia
-CORRECT ANSWER- c. Hypotension
*Rationale: Epidural anesthesia blocks sympathetic nerve fibers, leading to
vasodilation below the level of the block. This vasodilation reduces systemic vascular
resistance and venous return to the heart, causing maternal hypotension. Hypotension can
then reduce placental blood flow, leading to fetal distress manifested by late decelerations
on the fetal monitor. Prevention includes a fluid bolus of 500-1000 mL of lactated
Ringer's solution before epidural placement and positioning the mother in left lateral tilt
to improve venous return. Ephedrine or phenylephrine may be given if hypotension
occurs.*
8. A nurse is caring for a client who has trichomoniasis and a prescription for
metronidazole. Which of the following instructions should the nurse provide to the client
about the treatment plan?
a. "You can stop the medication once your symptoms disappear."
b. "Only you need to take the medication since you have symptoms."
c. "You and your partner need to take the medication and use a condom during
intercourse until cultures are negative."
d. "Avoid all sexual activity for one week after treatment."
-CORRECT ANSWER- c. "You and your partner need to take the medication and use a
condom during intercourse until cultures are negative."
*Rationale: Trichomoniasis is a sexually transmitted infection caused by Trichomonas
, vaginalis, and it has a high rate of reinfection if partners are not treated simultaneously.
Both partners must complete the full course of metronidazole, even if asymptomatic, to
prevent the "ping-pong" effect of passing the infection back and forth. Condoms should
be used consistently until follow-up cultures confirm negative results, which is typically
about one week after completing treatment. Alcohol must also be avoided during and for
48-72 hours after metronidazole to prevent a disulfiram-like reaction.*
9. A nurse in a prenatal clinic is caring for a client who is within the recommended
guideline for weight. The client asks the nurse how much weight is safe for her to gain
during her pregnancy. Which of the following responses should the nurse make?
a. "A weight gain of 25 - 35 lbs is good"
b. "You should gain no more than 15 lbs"
c. "Gain as much as you feel you need"
d. "Keep your weight exactly the same"
-CORRECT ANSWER- *a. "A weight gain of 25 - 35 lbs is good"*
*Rationale: For a woman with a normal pre-pregnancy body mass index (BMI of
18.5-24.9), the Institute of Medicine recommends a total weight gain of 25 to 35 pounds
during pregnancy. This range supports adequate fetal growth while minimizing risks such
as gestational diabetes, hypertension, and postpartum weight retention. Underweight
women should gain 28-40 lbs, overweight women 15-25 lbs, and obese women 11-20 lbs.
Excessive or inadequate weight gain is associated with adverse outcomes including
preterm birth, large-for-gestational-age infants, and childhood obesity.*
10. A nurse is caring for a client who has a prescription for naloxone. Which of the following
is the intended action of the med in relation to the CNS?
a. Potentiate the effects of narcotics
b. Block effects of narcotics on the CNS
c. Stimulate opioid receptors
d. Increase respiratory depression
-CORRECT ANSWER- b. Block effects of narcotics on the CNS
*Rationale: Naloxone is a pure opioid antagonist that competitively binds to mu,
kappa, and delta opioid receptors in the central nervous system without activating them.
By doing so, it reverses all effects of opioid agonists, including respiratory depression,
sedation, analgesia, and euphoria. It is administered intravenously or intramuscularly for
suspected opioid overdose in both mothers and newborns. The onset of action is rapid (1-
2 minutes), but the duration is shorter than many opioids, so repeated doses or a
continuous infusion may be necessary to prevent recurrence of respiratory depression.*
11. A nurse is discussing diaphragm use with a client. Which of the following statements by
client indicates an understanding of the teaching?
a. "I should replace my diaphragm every 2 years"
b. "I can leave it in for up to 48 hours"
c. "I don't need to use spermicide with it"
d. "I should remove it immediately after intercourse"
2026–2027 | Complete & Verified Questions and Correct
Answers | Latest Updated Edition | Newest Premium PDF
Available on the Market
1. A nurse is planning care for a newborn who requires phototherapy for
hyperbilirubinemia. Which of the following actions should the nurse include in the plan
of care?
a. Keep the newborn swaddled in two blankets
b. Apply lotion to the newborn's skin every 2 hours
c. Ensure the newborn's eyes are closed before applying the eye shield
d. Position the newborn prone during therapy
-CORRECT ANSWER- c. Ensure the newborn's eyes are closed before applying the eye
shield
Rationale: Eye shields are essential during phototherapy to prevent retinal damage
from the intense blue light. Closing the newborn's eyes before applying the shield helps
protect the cornea from direct irritation or injury from the shield itself. Additionally,
keeping the eyes closed reduces the risk of corneal abrasions and ensures that the eye
shield fits properly without causing discomfort. The nurse should also ensure the shield is
secured but not too tight, and remove it during feeding times to allow for eye contact and
assessment.
2. A nurse is caring for a client at 34 weeks gestation who has a prescription for terbutaline
for preterm labor. Which of the following statements by the patient is the priority?
a. "I have a mild headache"
b. "My hands shake a little"
c. "My heart feels as if it is racing"
d. "I feel more tired than usual"
-CORRECT ANSWER- c. "My heart feels as if it is racing"
*Rationale: Terbutaline is a beta-adrenergic agonist that stimulates beta-2 receptors in
the uterus to relax smooth muscle, but it also affects beta-1 receptors in the heart, leading
to tachycardia and palpitations. A racing heart sensation indicates significant cardiac
stimulation, which can progress to more serious complications such as pulmonary edema,
myocardial ischemia, or dysrhythmias. This finding is the priority because it directly
signals potential cardiovascular compromise. While tremors and headache are common
side effects, they are less immediately life-threatening than tachycardia.*
3. A nurse is planning care for a client who is pregnant and is Rh-negative. In which of the
following situations should the nurse administer Rh(D) Immune Globulin?
a. Before chorionic villus sampling
b. Only after delivery of an Rh-positive infant
, c. At 28 weeks of gestation
d. After an uncomplicated first trimester
-CORRECT ANSWER- c. At 28 weeks of gestation
*Rationale: Rh(D) Immune Globulin is given at 28 weeks of gestation as routine
antepartum prophylaxis to prevent Rh sensitization in an Rh-negative mother carrying an
Rh-positive fetus. At this gestational age, fetomaternal hemorrhage becomes more likely
due to normal placental changes, and even small amounts of fetal blood entering the
maternal circulation can trigger antibody formation. Preventing sensitization during
pregnancy is critical because antibodies formed now could affect future pregnancies,
causing hemolytic disease of the newborn. The 28-week dose is standard along with a
postpartum dose if the infant is Rh-positive.*
4. A nurse is caring for a client who is at 39 weeks of gestation and is in active labor. Which
of the following actions should the nurse include in the plan of care?
a. Administer analgesics as soon as the client requests them
b. Check the cervix prior to analgesic administration
c. Give oral fluids liberally throughout labor
d. Apply warm compresses to the perineum only after delivery
-CORRECT ANSWER- b. Check the cervix prior to analgesic administration
Rationale: Before administering systemic analgesics or epidural anesthesia, the
nurse must perform a cervical exam to determine the stage and progress of labor. If labor
is too advanced (typically 8 cm or more), administering analgesics can lead to neonatal
respiratory depression if delivery occurs soon after. Additionally, giving pain medication
too close to delivery may interfere with the mother's ability to push effectively. Cervical
assessment ensures that the timing of analgesia is safe for both mother and fetus, and it
also helps prevent unintended delivery of a newborn affected by the medication.
5. A nurse is planning care for a client who is at 35 weeks of gestation. Which of the
following lab tests should the nurse obtain?
a. Rubella titer
b. Group B streptococcus Beta-hemolytic (GBS)
c. Hemoglobin A1c
d. Thyroid stimulating hormone
-CORRECT ANSWER- b. Group B streptococcus Beta-hemolytic (GBS)
Rationale: The Centers for Disease Control and Prevention recommends universal
GBS screening for all pregnant women at 35 to 37 weeks of gestation. GBS is a leading
cause of neonatal sepsis, pneumonia, and meningitis. A positive result requires
intrapartum antibiotic prophylaxis to reduce vertical transmission during delivery.
Screening earlier may miss colonization that occurs later in pregnancy, while screening
after 37 weeks may not leave enough time to obtain results before delivery. Rubella titer
is typically done early in pregnancy, while Hgb A1c is for diabetic clients and TSH is for
thyroid disorders.
,6. A nurse is caring for a newborn whose mother received magnesium sulfate to treat
preterm labor. Which of the following clinical manifestations in the newborn indicates
toxicity due to the magnesium sulfate therapy?
a. Hyperreflexia
b. Respiratory depression
c. Excessive crying
d. Tachycardia
-CORRECT ANSWER- b. Respiratory depression
Rationale: Magnesium sulfate readily crosses the placenta and can cause neonatal
magnesium toxicity, especially if maternal levels are high or if the infant is premature.
The most serious and life-threatening sign of toxicity is respiratory depression, which
occurs because magnesium acts as a central nervous system depressant and can weaken
the respiratory muscles. Other signs of hypermagnesemia in the newborn include
hypotonia, lethargy, poor sucking reflex, and hyporeflexia. Hyperreflexia and excessive
crying are not associated with magnesium toxicity; they are more consistent with
neonatal abstinence syndrome or other conditions.
7. A nurse is caring for a client who is in labor and has an epidural for pain relief. Which of
the following is a complication from the epidural block?
a. Hypertension
b. Tachycardia
c. Hypotension
d. Hyperthermia
-CORRECT ANSWER- c. Hypotension
*Rationale: Epidural anesthesia blocks sympathetic nerve fibers, leading to
vasodilation below the level of the block. This vasodilation reduces systemic vascular
resistance and venous return to the heart, causing maternal hypotension. Hypotension can
then reduce placental blood flow, leading to fetal distress manifested by late decelerations
on the fetal monitor. Prevention includes a fluid bolus of 500-1000 mL of lactated
Ringer's solution before epidural placement and positioning the mother in left lateral tilt
to improve venous return. Ephedrine or phenylephrine may be given if hypotension
occurs.*
8. A nurse is caring for a client who has trichomoniasis and a prescription for
metronidazole. Which of the following instructions should the nurse provide to the client
about the treatment plan?
a. "You can stop the medication once your symptoms disappear."
b. "Only you need to take the medication since you have symptoms."
c. "You and your partner need to take the medication and use a condom during
intercourse until cultures are negative."
d. "Avoid all sexual activity for one week after treatment."
-CORRECT ANSWER- c. "You and your partner need to take the medication and use a
condom during intercourse until cultures are negative."
*Rationale: Trichomoniasis is a sexually transmitted infection caused by Trichomonas
, vaginalis, and it has a high rate of reinfection if partners are not treated simultaneously.
Both partners must complete the full course of metronidazole, even if asymptomatic, to
prevent the "ping-pong" effect of passing the infection back and forth. Condoms should
be used consistently until follow-up cultures confirm negative results, which is typically
about one week after completing treatment. Alcohol must also be avoided during and for
48-72 hours after metronidazole to prevent a disulfiram-like reaction.*
9. A nurse in a prenatal clinic is caring for a client who is within the recommended
guideline for weight. The client asks the nurse how much weight is safe for her to gain
during her pregnancy. Which of the following responses should the nurse make?
a. "A weight gain of 25 - 35 lbs is good"
b. "You should gain no more than 15 lbs"
c. "Gain as much as you feel you need"
d. "Keep your weight exactly the same"
-CORRECT ANSWER- *a. "A weight gain of 25 - 35 lbs is good"*
*Rationale: For a woman with a normal pre-pregnancy body mass index (BMI of
18.5-24.9), the Institute of Medicine recommends a total weight gain of 25 to 35 pounds
during pregnancy. This range supports adequate fetal growth while minimizing risks such
as gestational diabetes, hypertension, and postpartum weight retention. Underweight
women should gain 28-40 lbs, overweight women 15-25 lbs, and obese women 11-20 lbs.
Excessive or inadequate weight gain is associated with adverse outcomes including
preterm birth, large-for-gestational-age infants, and childhood obesity.*
10. A nurse is caring for a client who has a prescription for naloxone. Which of the following
is the intended action of the med in relation to the CNS?
a. Potentiate the effects of narcotics
b. Block effects of narcotics on the CNS
c. Stimulate opioid receptors
d. Increase respiratory depression
-CORRECT ANSWER- b. Block effects of narcotics on the CNS
*Rationale: Naloxone is a pure opioid antagonist that competitively binds to mu,
kappa, and delta opioid receptors in the central nervous system without activating them.
By doing so, it reverses all effects of opioid agonists, including respiratory depression,
sedation, analgesia, and euphoria. It is administered intravenously or intramuscularly for
suspected opioid overdose in both mothers and newborns. The onset of action is rapid (1-
2 minutes), but the duration is shorter than many opioids, so repeated doses or a
continuous infusion may be necessary to prevent recurrence of respiratory depression.*
11. A nurse is discussing diaphragm use with a client. Which of the following statements by
client indicates an understanding of the teaching?
a. "I should replace my diaphragm every 2 years"
b. "I can leave it in for up to 48 hours"
c. "I don't need to use spermicide with it"
d. "I should remove it immediately after intercourse"
