### 2026 NCLEX-Style Maternal & Newborn
Nursing Exam Prep | Verified Rationales |
Complete Success Pack for BSN Pathway Students
**100 Questions with Verified Rationales**
---
**1. A nurse is caring for a client at 38 weeks gestation who reports a sudden gush of clear fluid from
the vagina. Which of the following actions should the nurse take first?**
A) Perform a sterile vaginal exam to assess for cord prolapse
B) Assess the fluid for color, odor, and amount
C) Administer antibiotics to prevent infection
D) Apply an external fetal monitor
🎯CORRECT CHOICE: B
💡EXPLANATION: The first action is to assess the characteristics of the fluid to confirm if it is amniotic
fluid. Amniotic fluid is typically clear and odorless. Meconium-stained fluid (green or brown) or foul-
smelling fluid indicates potential fetal distress or infection, which requires immediate intervention.
**2. A postpartum client who is Rh-negative has just given birth to an Rh-positive infant. The nurse
should anticipate administering which of the following medications?**
A) Rh immunoglobulin (RhoGAM)
B) Hepatitis B vaccine
C) Vitamin K
D) Erythropoietin
🎯CORRECT CHOICE: A
💡EXPLANATION: Rh immunoglobulin (RhoGAM) is administered to Rh-negative mothers within 72
hours of birth to prevent isoimmunization. It works by binding to and destroying any Rh-positive fetal
,red blood cells that have entered the maternal circulation, thus preventing the mother's immune system
from forming anti-Rh antibodies.
**3. A nurse is assessing a newborn who is 12 hours old. Which of the following findings should be
reported to the healthcare provider?**
A) Axillary temperature of 36.1°C (97.0°F)
B) Heart rate of 140 beats per minute
C) Respiratory rate of 40 breaths per minute
D) Acrocyanosis of the hands and feet
🎯CORRECT CHOICE: A
💡EXPLANATION: A temperature of 36.1°C (97.0°F) is below the normal axillary range for a newborn
(36.5°C to 37.5°C / 97.7°F to 99.5°F) and indicates hypothermia. Newborns are at high risk for cold
stress, which can lead to hypoglycemia, hypoxia, and acidosis.
**4. A nurse is providing education to a client in the first trimester of pregnancy. Which of the following
statements by the client indicates an understanding of the teaching regarding folic acid?**
A) "I will start taking folic acid once I reach the third trimester."
B) "I will continue taking my 400 mcg of folic acid every day."
C) "I only need to take folic acid if I have a family history of birth defects."
D) "I can stop taking folic acid now that I am pregnant."
🎯CORRECT CHOICE: B
💡EXPLANATION: The recommended daily allowance of folic acid for all women of childbearing age is
400 mcg. Adequate folic acid intake before and during early pregnancy is crucial for preventing neural
tube defects. It should be continued throughout pregnancy.
**5. A nurse is assessing a client at 32 weeks gestation. The client reports headaches, blurred vision, and
epigastric pain. Which of the following conditions should the nurse suspect?**
A) Gestational diabetes
B) Preeclampsia with severe features
C) Placenta previa
D) Hyperemesis gravidarum
,🎯CORRECT CHOICE: B
💡EXPLANATION: Headache, visual disturbances, and epigastric pain are classic signs of preeclampsia
with severe features, indicating potential end-organ damage (such as the liver or brain) and an elevated
risk of eclampsia. Immediate assessment of blood pressure and proteinuria is necessary.
**6. A nurse is performing a newborn assessment and notes a bluish discoloration of the hands and
feet. The trunk and oral mucosa remain pink. How should the nurse document this finding?**
A) Cyanosis
B) Acrocyanosis
C) Harlequin sign
D) Erythema toxicum
🎯CORRECT CHOICE: B
💡EXPLANATION: Acrocyanosis is a common, benign finding in newborns characterized by peripheral
cyanosis (bluish discoloration of the hands and feet) with a pink central body. It is due to immature
peripheral circulation and is not a sign of respiratory or cardiac distress.
**7. A nurse is caring for a client in active labor. The fetal heart rate tracing shows late decelerations.
Which of the following is the priority nursing action?**
A) Increase the rate of oxytocin infusion
B) Reposition the client to a lateral position
C) Administer oxygen via face mask
D) Prepare for an immediate cesarean birth
🎯CORRECT CHOICE: B
💡EXPLANATION: Late decelerations indicate uteroplacental insufficiency. The priority action is to
increase uterine blood flow and placental perfusion. Repositioning the client to a left or right lateral
position relieves vena cava compression and improves blood flow to the uterus.
**8. A nurse is providing discharge teaching to a client following a cesarean birth. Which of the following
statements indicates a need for further teaching?**
A) "I will wait at least 6 weeks before resuming sexual activity."
B) "I will lift my toddler who weighs 35 pounds to prevent strain on my scar."
C) "I will take my pain medication as prescribed."
, D) "I will report any signs of infection at the incision site."
🎯CORRECT CHOICE: B
💡EXPLANATION: After a cesarean birth, clients should avoid heavy lifting (typically over 10-15 pounds)
for 4-6 weeks to allow the incision to heal and prevent complications like hernias or wound dehiscence.
Lifting a 35-pound toddler is contraindicated.
**9. A client at 40 weeks gestation is receiving an oxytocin infusion. During the infusion, the nurse notes
the contractions are lasting 110 seconds and occurring every 90 seconds. What is the priority nursing
action?**
A) Continue the infusion and monitor closely
B) Discontinue the oxytocin infusion
C) Decrease the infusion rate by half
D) Administer terbutaline to stop contractions
🎯CORRECT CHOICE: B
💡EXPLANATION: This pattern indicates uterine hyperstimulation (tachysystole), which can lead to fetal
hypoxia and uterine rupture. The priority action is to stop the oxytocin infusion immediately to allow the
uterus to relax and restore placental blood flow.
**10. A nurse is assessing a newborn for signs of hypoglycemia. Which of the following findings is a
classic early manifestation?**
A) Jitteriness
B) Respiratory distress
C) Jaundice
D) Tachycardia
🎯CORRECT CHOICE: A
💡EXPLANATION: Jitteriness, or tremors, is a common early sign of hypoglycemia in a newborn, which is
often due to hyperinsulinism in infants of diabetic mothers or inadequate glycogen stores. Other signs
include lethargy, poor feeding, and hypothermia.
**11. A nurse is providing teaching to a prenatal client about the signs of preterm labor. Which of the
following symptoms should the client be taught to report? (Select all that apply.)**
A) Menstrual-like cramps
Nursing Exam Prep | Verified Rationales |
Complete Success Pack for BSN Pathway Students
**100 Questions with Verified Rationales**
---
**1. A nurse is caring for a client at 38 weeks gestation who reports a sudden gush of clear fluid from
the vagina. Which of the following actions should the nurse take first?**
A) Perform a sterile vaginal exam to assess for cord prolapse
B) Assess the fluid for color, odor, and amount
C) Administer antibiotics to prevent infection
D) Apply an external fetal monitor
🎯CORRECT CHOICE: B
💡EXPLANATION: The first action is to assess the characteristics of the fluid to confirm if it is amniotic
fluid. Amniotic fluid is typically clear and odorless. Meconium-stained fluid (green or brown) or foul-
smelling fluid indicates potential fetal distress or infection, which requires immediate intervention.
**2. A postpartum client who is Rh-negative has just given birth to an Rh-positive infant. The nurse
should anticipate administering which of the following medications?**
A) Rh immunoglobulin (RhoGAM)
B) Hepatitis B vaccine
C) Vitamin K
D) Erythropoietin
🎯CORRECT CHOICE: A
💡EXPLANATION: Rh immunoglobulin (RhoGAM) is administered to Rh-negative mothers within 72
hours of birth to prevent isoimmunization. It works by binding to and destroying any Rh-positive fetal
,red blood cells that have entered the maternal circulation, thus preventing the mother's immune system
from forming anti-Rh antibodies.
**3. A nurse is assessing a newborn who is 12 hours old. Which of the following findings should be
reported to the healthcare provider?**
A) Axillary temperature of 36.1°C (97.0°F)
B) Heart rate of 140 beats per minute
C) Respiratory rate of 40 breaths per minute
D) Acrocyanosis of the hands and feet
🎯CORRECT CHOICE: A
💡EXPLANATION: A temperature of 36.1°C (97.0°F) is below the normal axillary range for a newborn
(36.5°C to 37.5°C / 97.7°F to 99.5°F) and indicates hypothermia. Newborns are at high risk for cold
stress, which can lead to hypoglycemia, hypoxia, and acidosis.
**4. A nurse is providing education to a client in the first trimester of pregnancy. Which of the following
statements by the client indicates an understanding of the teaching regarding folic acid?**
A) "I will start taking folic acid once I reach the third trimester."
B) "I will continue taking my 400 mcg of folic acid every day."
C) "I only need to take folic acid if I have a family history of birth defects."
D) "I can stop taking folic acid now that I am pregnant."
🎯CORRECT CHOICE: B
💡EXPLANATION: The recommended daily allowance of folic acid for all women of childbearing age is
400 mcg. Adequate folic acid intake before and during early pregnancy is crucial for preventing neural
tube defects. It should be continued throughout pregnancy.
**5. A nurse is assessing a client at 32 weeks gestation. The client reports headaches, blurred vision, and
epigastric pain. Which of the following conditions should the nurse suspect?**
A) Gestational diabetes
B) Preeclampsia with severe features
C) Placenta previa
D) Hyperemesis gravidarum
,🎯CORRECT CHOICE: B
💡EXPLANATION: Headache, visual disturbances, and epigastric pain are classic signs of preeclampsia
with severe features, indicating potential end-organ damage (such as the liver or brain) and an elevated
risk of eclampsia. Immediate assessment of blood pressure and proteinuria is necessary.
**6. A nurse is performing a newborn assessment and notes a bluish discoloration of the hands and
feet. The trunk and oral mucosa remain pink. How should the nurse document this finding?**
A) Cyanosis
B) Acrocyanosis
C) Harlequin sign
D) Erythema toxicum
🎯CORRECT CHOICE: B
💡EXPLANATION: Acrocyanosis is a common, benign finding in newborns characterized by peripheral
cyanosis (bluish discoloration of the hands and feet) with a pink central body. It is due to immature
peripheral circulation and is not a sign of respiratory or cardiac distress.
**7. A nurse is caring for a client in active labor. The fetal heart rate tracing shows late decelerations.
Which of the following is the priority nursing action?**
A) Increase the rate of oxytocin infusion
B) Reposition the client to a lateral position
C) Administer oxygen via face mask
D) Prepare for an immediate cesarean birth
🎯CORRECT CHOICE: B
💡EXPLANATION: Late decelerations indicate uteroplacental insufficiency. The priority action is to
increase uterine blood flow and placental perfusion. Repositioning the client to a left or right lateral
position relieves vena cava compression and improves blood flow to the uterus.
**8. A nurse is providing discharge teaching to a client following a cesarean birth. Which of the following
statements indicates a need for further teaching?**
A) "I will wait at least 6 weeks before resuming sexual activity."
B) "I will lift my toddler who weighs 35 pounds to prevent strain on my scar."
C) "I will take my pain medication as prescribed."
, D) "I will report any signs of infection at the incision site."
🎯CORRECT CHOICE: B
💡EXPLANATION: After a cesarean birth, clients should avoid heavy lifting (typically over 10-15 pounds)
for 4-6 weeks to allow the incision to heal and prevent complications like hernias or wound dehiscence.
Lifting a 35-pound toddler is contraindicated.
**9. A client at 40 weeks gestation is receiving an oxytocin infusion. During the infusion, the nurse notes
the contractions are lasting 110 seconds and occurring every 90 seconds. What is the priority nursing
action?**
A) Continue the infusion and monitor closely
B) Discontinue the oxytocin infusion
C) Decrease the infusion rate by half
D) Administer terbutaline to stop contractions
🎯CORRECT CHOICE: B
💡EXPLANATION: This pattern indicates uterine hyperstimulation (tachysystole), which can lead to fetal
hypoxia and uterine rupture. The priority action is to stop the oxytocin infusion immediately to allow the
uterus to relax and restore placental blood flow.
**10. A nurse is assessing a newborn for signs of hypoglycemia. Which of the following findings is a
classic early manifestation?**
A) Jitteriness
B) Respiratory distress
C) Jaundice
D) Tachycardia
🎯CORRECT CHOICE: A
💡EXPLANATION: Jitteriness, or tremors, is a common early sign of hypoglycemia in a newborn, which is
often due to hyperinsulinism in infants of diabetic mothers or inadequate glycogen stores. Other signs
include lethargy, poor feeding, and hypothermia.
**11. A nurse is providing teaching to a prenatal client about the signs of preterm labor. Which of the
following symptoms should the client be taught to report? (Select all that apply.)**
A) Menstrual-like cramps
