MATERNAL–NEWBORN NURSING FINAL EXAM
ACTUAL EXAM QUESTIONS AND CORRECT
ANSWERS WITH RATIONALES GRADED A+
LATEST
1. A client at 36 weeks gestation reports painless vaginal bleeding. Which
condition should the nurse suspect?
A. Placenta previa
B. Abruptio placentae
C. Preterm labor
D. Ectopic pregnancy
Answer: A. Placenta previa
Rationale: Placenta previa typically presents as painless, bright-red vaginal
bleeding in the third trimester. Abruptio placentae usually causes painful
bleeding, and preterm labor involves contractions. Ectopic pregnancy occurs
earlier in gestation and often causes abdominal pain.
2. A newborn’s APGAR score at 1 minute is 6. What is the priority nursing
action?
A. Provide immediate resuscitation
B. Reassess at 5 minutes and support as needed
C. Notify the provider immediately
D. Administer oxygen via mask
Answer: B. Reassess at 5 minutes and support as needed
Rationale: An APGAR score of 6 indicates mild distress. Standard practice is to
provide supportive care and reassess at 5 minutes, as many infants improve
with minimal interventions. Immediate resuscitation is reserved for scores 0–3.
,3. A postpartum client with a cesarean section asks why she needs to ambulate
early. What is the best explanation?
A. “It helps prevent infection in your incision.”
B. “It reduces the risk of blood clots.”
C. “It ensures your uterus will contract.”
D. “It prevents urinary retention.”
Answer: B. “It reduces the risk of blood clots.”
Rationale: Early ambulation after cesarean birth promotes circulation and
reduces the risk of venous thromboembolism. While ambulation has other
benefits, clot prevention is the primary rationale.
4. During labor, the nurse notes the fetal heart rate decelerates after
contractions and returns to baseline afterward. This is called:
A. Early decelerations
B. Late decelerations
C. Variable decelerations
D. Sinusoidal pattern
Answer: A. Early decelerations
Rationale: Early decelerations mirror contractions and are usually benign, caused
by fetal head compression. Late decelerations indicate uteroplacental
insufficiency, and variable decelerations suggest cord compression.
5. A breastfeeding mother reports nipple soreness. Which intervention should
the nurse suggest?
A. Apply alcohol before feeding
B. Adjust the infant’s latch
C. Wash nipples with soap frequently
D. Limit breastfeeding to 5 minutes per breast
Answer: B. Adjust the infant’s latch
Rationale: Nipple soreness is commonly due to improper latch. Correct
positioning prevents trauma. Alcohol and soap can dry and irritate nipples;
limiting feeding may reduce milk intake.
,6. A client in labor has a blood pressure of 160/110 mmHg and 3+ proteinuria.
Which complication is most likely?
A. Gestational hypertension
B. Preeclampsia
C. Eclampsia
D. HELLP syndrome
Answer: B. Preeclampsia
Rationale: Severe hypertension plus proteinuria indicates preeclampsia.
Eclampsia involves seizures, and HELLP syndrome includes hemolysis, elevated
liver enzymes, and low platelets.
7. A newborn is hypoglycemic (blood glucose 30 mg/dL). Which nursing
intervention is priority?
A. Provide a glucose gel or formula feeding
B. Obtain a serum glucose for confirmation
C. Notify the physician immediately
D. Initiate IV fluids
Answer: A. Provide a glucose gel or formula feeding
Rationale: Immediate feeding helps raise blood glucose. Confirmation and
physician notification follow, but intervention should not be delayed, especially
in symptomatic or at-risk neonates.
8. A client reports a sudden gush of fluid at 37 weeks. What is the priority
nursing action?
A. Assess for fetal distress and check gestational age
B. Obtain a CBC and urinalysis
C. Encourage ambulation
D. Document and reassure
Answer: A. Assess for fetal distress and check gestational age
, Rationale: Sudden fluid loss suggests rupture of membranes. It is important to
assess for labor, infection, and fetal well-being. Other interventions are
secondary.
9. During a postpartum assessment, the nurse notes the fundus is boggy.
Which action is most appropriate?
A. Encourage the client to void
B. Massage the fundus
C. Administer a diuretic
D. Increase IV fluids
Answer: B. Massage the fundus
Rationale: A boggy uterus indicates uterine atony, a leading cause of postpartum
hemorrhage. Fundal massage stimulates contraction. Voiding is important but
secondary.
10. A newborn is 38 weeks gestation, tachypneic, grunting, and has nasal
flaring. Which condition is most likely?
A. Transient tachypnea of the newborn
B. Meconium aspiration syndrome
C. Respiratory distress syndrome
D. Congenital heart defect
Answer: A. Transient tachypnea of the newborn
Rationale: TTN often occurs in term infants, especially after cesarean birth.
Symptoms include tachypnea, grunting, nasal flaring, and mild retractions. RDS
is more common in preterm infants.
ACTUAL EXAM QUESTIONS AND CORRECT
ANSWERS WITH RATIONALES GRADED A+
LATEST
1. A client at 36 weeks gestation reports painless vaginal bleeding. Which
condition should the nurse suspect?
A. Placenta previa
B. Abruptio placentae
C. Preterm labor
D. Ectopic pregnancy
Answer: A. Placenta previa
Rationale: Placenta previa typically presents as painless, bright-red vaginal
bleeding in the third trimester. Abruptio placentae usually causes painful
bleeding, and preterm labor involves contractions. Ectopic pregnancy occurs
earlier in gestation and often causes abdominal pain.
2. A newborn’s APGAR score at 1 minute is 6. What is the priority nursing
action?
A. Provide immediate resuscitation
B. Reassess at 5 minutes and support as needed
C. Notify the provider immediately
D. Administer oxygen via mask
Answer: B. Reassess at 5 minutes and support as needed
Rationale: An APGAR score of 6 indicates mild distress. Standard practice is to
provide supportive care and reassess at 5 minutes, as many infants improve
with minimal interventions. Immediate resuscitation is reserved for scores 0–3.
,3. A postpartum client with a cesarean section asks why she needs to ambulate
early. What is the best explanation?
A. “It helps prevent infection in your incision.”
B. “It reduces the risk of blood clots.”
C. “It ensures your uterus will contract.”
D. “It prevents urinary retention.”
Answer: B. “It reduces the risk of blood clots.”
Rationale: Early ambulation after cesarean birth promotes circulation and
reduces the risk of venous thromboembolism. While ambulation has other
benefits, clot prevention is the primary rationale.
4. During labor, the nurse notes the fetal heart rate decelerates after
contractions and returns to baseline afterward. This is called:
A. Early decelerations
B. Late decelerations
C. Variable decelerations
D. Sinusoidal pattern
Answer: A. Early decelerations
Rationale: Early decelerations mirror contractions and are usually benign, caused
by fetal head compression. Late decelerations indicate uteroplacental
insufficiency, and variable decelerations suggest cord compression.
5. A breastfeeding mother reports nipple soreness. Which intervention should
the nurse suggest?
A. Apply alcohol before feeding
B. Adjust the infant’s latch
C. Wash nipples with soap frequently
D. Limit breastfeeding to 5 minutes per breast
Answer: B. Adjust the infant’s latch
Rationale: Nipple soreness is commonly due to improper latch. Correct
positioning prevents trauma. Alcohol and soap can dry and irritate nipples;
limiting feeding may reduce milk intake.
,6. A client in labor has a blood pressure of 160/110 mmHg and 3+ proteinuria.
Which complication is most likely?
A. Gestational hypertension
B. Preeclampsia
C. Eclampsia
D. HELLP syndrome
Answer: B. Preeclampsia
Rationale: Severe hypertension plus proteinuria indicates preeclampsia.
Eclampsia involves seizures, and HELLP syndrome includes hemolysis, elevated
liver enzymes, and low platelets.
7. A newborn is hypoglycemic (blood glucose 30 mg/dL). Which nursing
intervention is priority?
A. Provide a glucose gel or formula feeding
B. Obtain a serum glucose for confirmation
C. Notify the physician immediately
D. Initiate IV fluids
Answer: A. Provide a glucose gel or formula feeding
Rationale: Immediate feeding helps raise blood glucose. Confirmation and
physician notification follow, but intervention should not be delayed, especially
in symptomatic or at-risk neonates.
8. A client reports a sudden gush of fluid at 37 weeks. What is the priority
nursing action?
A. Assess for fetal distress and check gestational age
B. Obtain a CBC and urinalysis
C. Encourage ambulation
D. Document and reassure
Answer: A. Assess for fetal distress and check gestational age
, Rationale: Sudden fluid loss suggests rupture of membranes. It is important to
assess for labor, infection, and fetal well-being. Other interventions are
secondary.
9. During a postpartum assessment, the nurse notes the fundus is boggy.
Which action is most appropriate?
A. Encourage the client to void
B. Massage the fundus
C. Administer a diuretic
D. Increase IV fluids
Answer: B. Massage the fundus
Rationale: A boggy uterus indicates uterine atony, a leading cause of postpartum
hemorrhage. Fundal massage stimulates contraction. Voiding is important but
secondary.
10. A newborn is 38 weeks gestation, tachypneic, grunting, and has nasal
flaring. Which condition is most likely?
A. Transient tachypnea of the newborn
B. Meconium aspiration syndrome
C. Respiratory distress syndrome
D. Congenital heart defect
Answer: A. Transient tachypnea of the newborn
Rationale: TTN often occurs in term infants, especially after cesarean birth.
Symptoms include tachypnea, grunting, nasal flaring, and mild retractions. RDS
is more common in preterm infants.
