RN Maternal Newborn 2026
Question 1
A nurse is assessing a client who is at 34 weeks of gestation during a prenatal visit. Which
finding should the nurse report to the provider immediately?
A. Blood pressure 118/72 mm Hg
B. Fundal height measuring 34 cm
C. Mild dependent edema of the feet at the end of the day
D. Persistent headache with blurred vision
Correct Answer: D
Rationale: Persistent headache and blurred vision are signs of severe preeclampsia and require
immediate evaluation.
,Question 2
A nurse is caring for a client in labor. Which assessment finding indicates the client has entered
the active phase of the first stage of labor?
A. Cervix dilated to 3 cm and 80% effaced
B. Cervix dilated to 6 cm and 100% effaced
C. Cervix fully dilated to 10 cm
D. Delivery of the placenta
Correct Answer: B
Rationale: The active phase of labor generally begins at 6 cm cervical dilation and continues
until complete dilation.
,Question 3
A nurse is monitoring fetal heart rate during labor and observes recurrent late decelerations.
Which action should the nurse take first?
A. Increase the oxytocin infusion rate.
B. Place the client in a lateral position.
C. Encourage the client to bear down.
D. Prepare the client for discharge.
Correct Answer: B
Rationale: Repositioning the client improves uteroplacental blood flow and is the priority
intervention for late decelerations.
, Question 4
A nurse is caring for a client who delivered vaginally 30 minutes ago. The uterus is boggy, and
heavy vaginal bleeding is noted. Which action should the nurse perform first?
A. Massage the uterine fundus.
B. Insert an indwelling urinary catheter.
C. Administer methylergonovine.
D. Obtain a hemoglobin level.
Correct Answer: A
Rationale: A boggy uterus indicates uterine atony. Fundal massage is the first intervention to
stimulate uterine contraction.
Question 1
A nurse is assessing a client who is at 34 weeks of gestation during a prenatal visit. Which
finding should the nurse report to the provider immediately?
A. Blood pressure 118/72 mm Hg
B. Fundal height measuring 34 cm
C. Mild dependent edema of the feet at the end of the day
D. Persistent headache with blurred vision
Correct Answer: D
Rationale: Persistent headache and blurred vision are signs of severe preeclampsia and require
immediate evaluation.
,Question 2
A nurse is caring for a client in labor. Which assessment finding indicates the client has entered
the active phase of the first stage of labor?
A. Cervix dilated to 3 cm and 80% effaced
B. Cervix dilated to 6 cm and 100% effaced
C. Cervix fully dilated to 10 cm
D. Delivery of the placenta
Correct Answer: B
Rationale: The active phase of labor generally begins at 6 cm cervical dilation and continues
until complete dilation.
,Question 3
A nurse is monitoring fetal heart rate during labor and observes recurrent late decelerations.
Which action should the nurse take first?
A. Increase the oxytocin infusion rate.
B. Place the client in a lateral position.
C. Encourage the client to bear down.
D. Prepare the client for discharge.
Correct Answer: B
Rationale: Repositioning the client improves uteroplacental blood flow and is the priority
intervention for late decelerations.
, Question 4
A nurse is caring for a client who delivered vaginally 30 minutes ago. The uterus is boggy, and
heavy vaginal bleeding is noted. Which action should the nurse perform first?
A. Massage the uterine fundus.
B. Insert an indwelling urinary catheter.
C. Administer methylergonovine.
D. Obtain a hemoglobin level.
Correct Answer: A
Rationale: A boggy uterus indicates uterine atony. Fundal massage is the first intervention to
stimulate uterine contraction.
