Maternal-Newborn Nursing Exam –
Complete Exam 14 with Verified Answers
(2026 Edition)
Question 1: A nurse is caring for a client who is 38 weeks gestation and is in active labor. The client's
cervix is 7 cm dilated, 100% effaced, and the presenting part is at 0 station. The client is experiencing
contractions every 3-4 minutes lasting 60 seconds. Which stage and phase of labor is the client in?
A) Stage 1, latent phase
B) Stage 1, active phase
C) Stage 1, transition phase
D) Stage 2, descent phase
Answer: B) Stage 1, active phase
Rationale: The active phase of stage 1 labor is characterized by cervical dilation of 4-7 cm, full
effacement (100%), and the presenting part descending to 0 station. Contractions are every 3-5 minutes
and last 40-70 seconds. The latent phase is 0-3 cm dilation. The transition phase is 8-10 cm dilation.
Stage 2 begins at 10 cm dilation.
Question 2: A nurse is assessing a newborn who is 1 minute old. The heart rate is 130 bpm, respiratory
effort is strong crying, muscle tone is active, reflex irritability is sneezing, and the skin is pink all over.
What is the newborn's Apgar score?
A) 8
B) 9
C) 10
D) 7
Answer: C) 10
Rationale: Apgar scoring: Heart rate >100 = 2 points (130 bpm = 2); Respiratory effort good crying = 2;
Muscle tone active = 2; Reflex irritability sneezing = 2; Skin pink all over = 2. Total = 10. A score of 10
indicates a healthy newborn with no distress. Apgar scores are assessed at 1 and 5 minutes of life. Scores
of 7-10 are considered normal.
Question 3: A nurse is providing education to a client who is 12 weeks gestation about the first-
trimester screening. Which test is typically performed during the first trimester?
,A) Glucose tolerance test
B) Nuchal translucency (NT) ultrasound and maternal serum screening
C) Quadruple screen
D) Amniocentesis
Answer: B) Nuchal translucency (NT) ultrasound and maternal serum screening
Rationale: First-trimester screening (performed at 11-14 weeks) includes nuchal translucency (NT)
ultrasound to assess for Down syndrome and other chromosomal abnormalities, and maternal serum
screening (PAPP-A, beta-hCG). The glucose tolerance test is performed at 24-28 weeks for gestational
diabetes. The quadruple screen is performed at 15-20 weeks. Amniocentesis is performed at 15-20 weeks
for high-risk clients.
Question 4: A nurse is caring for a client with preeclampsia who is receiving magnesium sulfate. The
client's deep tendon reflexes are absent. Which action should the nurse take?
A) Continue the magnesium sulfate infusion
B) Decrease the magnesium sulfate infusion rate
C) Discontinue the magnesium sulfate infusion and notify the healthcare provider
D) Administer calcium gluconate
Answer: C) Discontinue the magnesium sulfate infusion and notify the healthcare provider
Rationale: Absent deep tendon reflexes indicate magnesium sulfate toxicity. The nurse should
discontinue the infusion and notify the healthcare provider immediately. Calcium gluconate is the
antidote for magnesium toxicity and should be administered as prescribed. The nurse should also
monitor the client's respiratory rate and urine output.
Question 5: A nurse is assessing a client who is 24 hours postpartum after a vaginal delivery. The client's
fundus is firm, at the umbilicus, and lochia rubra is moderate. The client reports perineal pain and
difficulty voiding. Which action should the nurse take first?
A) Administer prescribed pain medication
B) Assist the client to void
C) Apply ice packs to the perineum
D) Notify the healthcare provider
Answer: B) Assist the client to void
Rationale: Difficulty voiding can lead to a distended bladder, which can displace the uterus and cause
uterine atony and hemorrhage. The nurse should first assist the client to void. After voiding, the nurse
should assess the fundus and lochia. Pain medication and ice packs can be used for perineal discomfort
but should not be the first action.
, Question 6: A nurse is providing education to a client who is 28 weeks gestation about signs of preterm
labor. Which symptom should the client report immediately?
A) Regular uterine contractions
B) Lower back pain
C) Pelvic pressure
D) All of the above
Answer: D) All of the above
Rationale: Signs of preterm labor include regular uterine contractions (with or without pain), lower back
pain, pelvic pressure, change in vaginal discharge, and menstrual-like cramps. The client should report
any of these symptoms immediately. Early recognition and treatment of preterm labor can prevent
preterm birth. The nurse should also assess for risk factors (multiple gestation, smoking, infection, history
of preterm birth).
Question 7: A nurse is caring for a newborn who is 24 hours old. The newborn has jaundice on the face
and chest, and the bilirubin level is 14 mg/dL. Which action should the nurse take?
A) Continue to monitor the newborn's jaundice
B) Initiate phototherapy
C) Administer phenobarbital
D) Notify the healthcare provider
Answer: B) Initiate phototherapy
Rationale: At 24 hours of age, a bilirubin level of 14 mg/dL is elevated and requires phototherapy.
Phototherapy is the standard treatment for neonatal jaundice. The nurse should monitor the newborn's
temperature, hydration, and bilirubin levels during phototherapy. The newborn's eyes should be covered,
and the skin should be exposed as much as possible. The nurse should also encourage feeding to promote
bilirubin excretion.
Question 8: A nurse is assessing a client who is 34 weeks gestation and reports a sudden gush of fluid
from the vagina. The fluid is clear and has a sweet odor. Which action should the nurse take?
A) Perform a sterile speculum examination
B) Check the fluid with nitrazine paper
C) Notify the healthcare provider immediately
D) All of the above
Answer: D) All of the above
Rationale: The client may have experienced premature rupture of membranes (PROM). The nurse should
perform a sterile speculum examination, check the fluid with nitrazine paper (amniotic fluid turns
nitrazine paper blue), and notify the healthcare provider immediately. The nurse should also assess the
Complete Exam 14 with Verified Answers
(2026 Edition)
Question 1: A nurse is caring for a client who is 38 weeks gestation and is in active labor. The client's
cervix is 7 cm dilated, 100% effaced, and the presenting part is at 0 station. The client is experiencing
contractions every 3-4 minutes lasting 60 seconds. Which stage and phase of labor is the client in?
A) Stage 1, latent phase
B) Stage 1, active phase
C) Stage 1, transition phase
D) Stage 2, descent phase
Answer: B) Stage 1, active phase
Rationale: The active phase of stage 1 labor is characterized by cervical dilation of 4-7 cm, full
effacement (100%), and the presenting part descending to 0 station. Contractions are every 3-5 minutes
and last 40-70 seconds. The latent phase is 0-3 cm dilation. The transition phase is 8-10 cm dilation.
Stage 2 begins at 10 cm dilation.
Question 2: A nurse is assessing a newborn who is 1 minute old. The heart rate is 130 bpm, respiratory
effort is strong crying, muscle tone is active, reflex irritability is sneezing, and the skin is pink all over.
What is the newborn's Apgar score?
A) 8
B) 9
C) 10
D) 7
Answer: C) 10
Rationale: Apgar scoring: Heart rate >100 = 2 points (130 bpm = 2); Respiratory effort good crying = 2;
Muscle tone active = 2; Reflex irritability sneezing = 2; Skin pink all over = 2. Total = 10. A score of 10
indicates a healthy newborn with no distress. Apgar scores are assessed at 1 and 5 minutes of life. Scores
of 7-10 are considered normal.
Question 3: A nurse is providing education to a client who is 12 weeks gestation about the first-
trimester screening. Which test is typically performed during the first trimester?
,A) Glucose tolerance test
B) Nuchal translucency (NT) ultrasound and maternal serum screening
C) Quadruple screen
D) Amniocentesis
Answer: B) Nuchal translucency (NT) ultrasound and maternal serum screening
Rationale: First-trimester screening (performed at 11-14 weeks) includes nuchal translucency (NT)
ultrasound to assess for Down syndrome and other chromosomal abnormalities, and maternal serum
screening (PAPP-A, beta-hCG). The glucose tolerance test is performed at 24-28 weeks for gestational
diabetes. The quadruple screen is performed at 15-20 weeks. Amniocentesis is performed at 15-20 weeks
for high-risk clients.
Question 4: A nurse is caring for a client with preeclampsia who is receiving magnesium sulfate. The
client's deep tendon reflexes are absent. Which action should the nurse take?
A) Continue the magnesium sulfate infusion
B) Decrease the magnesium sulfate infusion rate
C) Discontinue the magnesium sulfate infusion and notify the healthcare provider
D) Administer calcium gluconate
Answer: C) Discontinue the magnesium sulfate infusion and notify the healthcare provider
Rationale: Absent deep tendon reflexes indicate magnesium sulfate toxicity. The nurse should
discontinue the infusion and notify the healthcare provider immediately. Calcium gluconate is the
antidote for magnesium toxicity and should be administered as prescribed. The nurse should also
monitor the client's respiratory rate and urine output.
Question 5: A nurse is assessing a client who is 24 hours postpartum after a vaginal delivery. The client's
fundus is firm, at the umbilicus, and lochia rubra is moderate. The client reports perineal pain and
difficulty voiding. Which action should the nurse take first?
A) Administer prescribed pain medication
B) Assist the client to void
C) Apply ice packs to the perineum
D) Notify the healthcare provider
Answer: B) Assist the client to void
Rationale: Difficulty voiding can lead to a distended bladder, which can displace the uterus and cause
uterine atony and hemorrhage. The nurse should first assist the client to void. After voiding, the nurse
should assess the fundus and lochia. Pain medication and ice packs can be used for perineal discomfort
but should not be the first action.
, Question 6: A nurse is providing education to a client who is 28 weeks gestation about signs of preterm
labor. Which symptom should the client report immediately?
A) Regular uterine contractions
B) Lower back pain
C) Pelvic pressure
D) All of the above
Answer: D) All of the above
Rationale: Signs of preterm labor include regular uterine contractions (with or without pain), lower back
pain, pelvic pressure, change in vaginal discharge, and menstrual-like cramps. The client should report
any of these symptoms immediately. Early recognition and treatment of preterm labor can prevent
preterm birth. The nurse should also assess for risk factors (multiple gestation, smoking, infection, history
of preterm birth).
Question 7: A nurse is caring for a newborn who is 24 hours old. The newborn has jaundice on the face
and chest, and the bilirubin level is 14 mg/dL. Which action should the nurse take?
A) Continue to monitor the newborn's jaundice
B) Initiate phototherapy
C) Administer phenobarbital
D) Notify the healthcare provider
Answer: B) Initiate phototherapy
Rationale: At 24 hours of age, a bilirubin level of 14 mg/dL is elevated and requires phototherapy.
Phototherapy is the standard treatment for neonatal jaundice. The nurse should monitor the newborn's
temperature, hydration, and bilirubin levels during phototherapy. The newborn's eyes should be covered,
and the skin should be exposed as much as possible. The nurse should also encourage feeding to promote
bilirubin excretion.
Question 8: A nurse is assessing a client who is 34 weeks gestation and reports a sudden gush of fluid
from the vagina. The fluid is clear and has a sweet odor. Which action should the nurse take?
A) Perform a sterile speculum examination
B) Check the fluid with nitrazine paper
C) Notify the healthcare provider immediately
D) All of the above
Answer: D) All of the above
Rationale: The client may have experienced premature rupture of membranes (PROM). The nurse should
perform a sterile speculum examination, check the fluid with nitrazine paper (amniotic fluid turns
nitrazine paper blue), and notify the healthcare provider immediately. The nurse should also assess the
