NCLEX Maternal-Newborn Nursing Test Bank Exam Verified Questions,
Correct Answers, and Detailed Explanations for Students||Already
Graded A+
Question 1
A nurse is caring for a client at 38 weeks' gestation who reports a
sudden gush of clear fluid from the vagina. What is the nurse's priority
action?
A. Perform a sterile vaginal examination immediately
B. Assess the fetal heart rate
C. Encourage the client to ambulate
D. Administer oxytocin
Correct Answer: B. Assess the Fetal Heart Rate
Rationale:
After rupture of membranes, the priority is to assess the fetal heart rate
to detect possible umbilical cord prolapse or fetal distress. A vaginal
examination should be avoided unless medically indicated because it
increases the risk of infection.
Question 2
A postpartum client has a boggy uterus and heavy vaginal bleeding.
Which nursing intervention should be performed first?
A. Notify the healthcare provider
B. Massage the uterine fundus
C. Administer pain medication
D. Encourage breastfeeding later
,Correct Answer: B. Massage the Uterine Fundus
Rationale:
A boggy uterus indicates uterine atony, the leading cause of postpartum
hemorrhage. Fundal massage promotes uterine contraction and helps
reduce bleeding.
Question 3
Which finding in a newborn requires immediate nursing intervention?
A. Heart rate of 130 beats/minute
B. Respiratory rate of 44 breaths/minute
C. Central cyanosis
D. Axillary temperature of 98.2°F (36.8°C)
Correct Answer: C. Central Cyanosis
Rationale:
Central cyanosis indicates inadequate oxygenation and requires
immediate assessment and intervention. Acrocyanosis of the hands and
feet is common shortly after birth and is generally normal.
Question 4
A client with preeclampsia is receiving magnesium sulfate. Which
assessment finding indicates possible magnesium toxicity?
A. Blood pressure of 150/94 mm Hg
B. Respiratory rate of 10 breaths/minute
,C. Hyperactive deep tendon reflexes
D. Urine output of 50 mL/hour
Correct Answer: B. Respiratory Rate of 10 Breaths/Minute
Rationale:
Respiratory depression, absent deep tendon reflexes, and decreased
urine output are signs of magnesium toxicity. Calcium gluconate should
be readily available as the antidote.
Question 5
Which newborn assessment finding is considered normal during the
first 24 hours after birth?
A. Persistent central cyanosis
B. Apical heart rate of 140 beats/minute
C. Absence of primitive reflexes
D. Respiratory rate of 18 breaths/minute
Correct Answer: B. Apical Heart Rate of 140 Beats/Minute
Rationale:
A normal newborn heart rate ranges from 110 to 160 beats/minute.
Persistent central cyanosis, absent reflexes, and significant bradypnea
are abnormal findings.
Question 6
A laboring client reports intense rectal pressure and an urge to push.
What should the nurse do first?
, A. Encourage pushing immediately
B. Assess cervical dilation
C. Administer an analgesic
D. Place the client in a supine position
Correct Answer: B. Assess Cervical Dilation
Rationale:
The nurse should determine whether the cervix is fully dilated before
encouraging pushing to prevent cervical injury.
Question 7
A postpartum client reports calf pain, warmth, and swelling in one leg.
Which action should the nurse take first?
A. Massage the affected leg
B. Encourage ambulation
C. Notify the healthcare provider immediately
D. Apply a heating pad
Correct Answer: C. Notify the Healthcare Provider Immediately
Rationale:
These findings suggest deep vein thrombosis (DVT). Massaging the leg
may dislodge a clot and increase the risk of pulmonary embolism.
Question 8
Which statement by a breastfeeding mother indicates a need for further
teaching?
Correct Answers, and Detailed Explanations for Students||Already
Graded A+
Question 1
A nurse is caring for a client at 38 weeks' gestation who reports a
sudden gush of clear fluid from the vagina. What is the nurse's priority
action?
A. Perform a sterile vaginal examination immediately
B. Assess the fetal heart rate
C. Encourage the client to ambulate
D. Administer oxytocin
Correct Answer: B. Assess the Fetal Heart Rate
Rationale:
After rupture of membranes, the priority is to assess the fetal heart rate
to detect possible umbilical cord prolapse or fetal distress. A vaginal
examination should be avoided unless medically indicated because it
increases the risk of infection.
Question 2
A postpartum client has a boggy uterus and heavy vaginal bleeding.
Which nursing intervention should be performed first?
A. Notify the healthcare provider
B. Massage the uterine fundus
C. Administer pain medication
D. Encourage breastfeeding later
,Correct Answer: B. Massage the Uterine Fundus
Rationale:
A boggy uterus indicates uterine atony, the leading cause of postpartum
hemorrhage. Fundal massage promotes uterine contraction and helps
reduce bleeding.
Question 3
Which finding in a newborn requires immediate nursing intervention?
A. Heart rate of 130 beats/minute
B. Respiratory rate of 44 breaths/minute
C. Central cyanosis
D. Axillary temperature of 98.2°F (36.8°C)
Correct Answer: C. Central Cyanosis
Rationale:
Central cyanosis indicates inadequate oxygenation and requires
immediate assessment and intervention. Acrocyanosis of the hands and
feet is common shortly after birth and is generally normal.
Question 4
A client with preeclampsia is receiving magnesium sulfate. Which
assessment finding indicates possible magnesium toxicity?
A. Blood pressure of 150/94 mm Hg
B. Respiratory rate of 10 breaths/minute
,C. Hyperactive deep tendon reflexes
D. Urine output of 50 mL/hour
Correct Answer: B. Respiratory Rate of 10 Breaths/Minute
Rationale:
Respiratory depression, absent deep tendon reflexes, and decreased
urine output are signs of magnesium toxicity. Calcium gluconate should
be readily available as the antidote.
Question 5
Which newborn assessment finding is considered normal during the
first 24 hours after birth?
A. Persistent central cyanosis
B. Apical heart rate of 140 beats/minute
C. Absence of primitive reflexes
D. Respiratory rate of 18 breaths/minute
Correct Answer: B. Apical Heart Rate of 140 Beats/Minute
Rationale:
A normal newborn heart rate ranges from 110 to 160 beats/minute.
Persistent central cyanosis, absent reflexes, and significant bradypnea
are abnormal findings.
Question 6
A laboring client reports intense rectal pressure and an urge to push.
What should the nurse do first?
, A. Encourage pushing immediately
B. Assess cervical dilation
C. Administer an analgesic
D. Place the client in a supine position
Correct Answer: B. Assess Cervical Dilation
Rationale:
The nurse should determine whether the cervix is fully dilated before
encouraging pushing to prevent cervical injury.
Question 7
A postpartum client reports calf pain, warmth, and swelling in one leg.
Which action should the nurse take first?
A. Massage the affected leg
B. Encourage ambulation
C. Notify the healthcare provider immediately
D. Apply a heating pad
Correct Answer: C. Notify the Healthcare Provider Immediately
Rationale:
These findings suggest deep vein thrombosis (DVT). Massaging the leg
may dislodge a clot and increase the risk of pulmonary embolism.
Question 8
Which statement by a breastfeeding mother indicates a need for further
teaching?
