1. A 29-year-old G2P1 client is admitted at 38 weeks gestation with regular
contractions every 3 minutes and cervical dilation of 6 cm. She requests an
epidural for pain relief. Her BP is 92/58 mmHg, HR 108 bpm, and fetal heart rate
is 100 bpm. What is the nurse’s priority action?
A. Turn the client to the left lateral position
B. Notify the anesthesiologist immediately
C. Increase IV fluids and apply oxygen
D. Reassess the fetal heart rate in 10 minutes
Correct Answer: C. Increase IV fluids and apply oxygen
Rationale: The client is showing signs of hypotension following an epidural,
which can lead to decreased placental perfusion and fetal bradycardia. Increasing
IV fluids and administering oxygen improves maternal and fetal oxygenation. Left
lateral positioning may follow, but stabilizing circulation takes precedence.
2. A postpartum client reports severe perineal pain unrelieved by ice packs and
analgesics 3 hours after vaginal delivery. Her fundus is firm and midline, and
lochia is minimal. Which condition is most likely?
A. Uterine atony
B. Perineal hematoma
,C. Retained placenta
D. Endometritis
Correct Answer: B. Perineal hematoma
Rationale: A firm uterus with minimal bleeding and severe unrelieved perineal
pain is indicative of a hematoma, not uterine atony. Hematomas result from blood
vessel injury during delivery, and can collect large amounts of blood internally
without visible bleeding.
3. A nurse is caring for a client with preeclampsia receiving magnesium sulfate.
Which of the following findings requires immediate nursing action?
A. Deep tendon reflexes +2
B. Urine output 40 mL/hr
C. Respiratory rate 10 breaths/min
D. Serum magnesium level of 5.2 mg/dL
Correct Answer: C. Respiratory rate 10 breaths/min
Rationale: Magnesium toxicity can depress respiratory function. A rate below 12
is dangerous and requires the nurse to stop the infusion and notify the provider.
Normal reflexes and output are expected. Magnesium >7 may be toxic, but
symptoms are more critical.
,4. A client at 35 weeks' gestation is admitted for preterm labor and receives
betamethasone. What is the primary purpose of this medication?
A. Reduce uterine contractions
B. Prevent maternal hypertension
C. Accelerate fetal lung maturity
D. Stimulate fetal movement
Correct Answer: C. Accelerate fetal lung maturity
Rationale: Betamethasone, a corticosteroid, promotes the production of
surfactant in the fetal lungs, which is crucial for preterm infants. It does not stop
labor or affect BP, and its benefit is primarily respiratory.
5. A nurse is caring for a newborn 2 hours after birth. The infant is jittery, has a
high-pitched cry, and a blood glucose of 35 mg/dL. What is the priority action?
A. Reassess blood glucose in 1 hour
B. Notify the provider immediately
C. Initiate breastfeeding or formula feeding
D. Swaddle and monitor closely
, Correct Answer: C. Initiate breastfeeding or formula feeding
Rationale: This is neonatal hypoglycemia, which must be treated immediately to
prevent neurologic damage. Feeding is the first-line intervention. A glucose <40 in
symptomatic newborns requires urgent action.
6. A client is receiving oxytocin to induce labor. Which finding requires immediate
discontinuation of the infusion?
A. Contractions every 3 minutes
B. Fetal heart rate of 170 bpm
C. Uterine contractions lasting 120 seconds
D. Client complains of back pain
Correct Answer: C. Uterine contractions lasting 120 seconds
Rationale: Prolonged contractions (>90 seconds) indicate uterine
hyperstimulation, risking uterine rupture and fetal distress. Oxytocin should be
stopped immediately. A FHR of 170 is mild tachycardia; back pain is common.
7. A nurse is providing discharge instructions to a client with a cesarean delivery.
Which statement indicates the need for further teaching?
contractions every 3 minutes and cervical dilation of 6 cm. She requests an
epidural for pain relief. Her BP is 92/58 mmHg, HR 108 bpm, and fetal heart rate
is 100 bpm. What is the nurse’s priority action?
A. Turn the client to the left lateral position
B. Notify the anesthesiologist immediately
C. Increase IV fluids and apply oxygen
D. Reassess the fetal heart rate in 10 minutes
Correct Answer: C. Increase IV fluids and apply oxygen
Rationale: The client is showing signs of hypotension following an epidural,
which can lead to decreased placental perfusion and fetal bradycardia. Increasing
IV fluids and administering oxygen improves maternal and fetal oxygenation. Left
lateral positioning may follow, but stabilizing circulation takes precedence.
2. A postpartum client reports severe perineal pain unrelieved by ice packs and
analgesics 3 hours after vaginal delivery. Her fundus is firm and midline, and
lochia is minimal. Which condition is most likely?
A. Uterine atony
B. Perineal hematoma
,C. Retained placenta
D. Endometritis
Correct Answer: B. Perineal hematoma
Rationale: A firm uterus with minimal bleeding and severe unrelieved perineal
pain is indicative of a hematoma, not uterine atony. Hematomas result from blood
vessel injury during delivery, and can collect large amounts of blood internally
without visible bleeding.
3. A nurse is caring for a client with preeclampsia receiving magnesium sulfate.
Which of the following findings requires immediate nursing action?
A. Deep tendon reflexes +2
B. Urine output 40 mL/hr
C. Respiratory rate 10 breaths/min
D. Serum magnesium level of 5.2 mg/dL
Correct Answer: C. Respiratory rate 10 breaths/min
Rationale: Magnesium toxicity can depress respiratory function. A rate below 12
is dangerous and requires the nurse to stop the infusion and notify the provider.
Normal reflexes and output are expected. Magnesium >7 may be toxic, but
symptoms are more critical.
,4. A client at 35 weeks' gestation is admitted for preterm labor and receives
betamethasone. What is the primary purpose of this medication?
A. Reduce uterine contractions
B. Prevent maternal hypertension
C. Accelerate fetal lung maturity
D. Stimulate fetal movement
Correct Answer: C. Accelerate fetal lung maturity
Rationale: Betamethasone, a corticosteroid, promotes the production of
surfactant in the fetal lungs, which is crucial for preterm infants. It does not stop
labor or affect BP, and its benefit is primarily respiratory.
5. A nurse is caring for a newborn 2 hours after birth. The infant is jittery, has a
high-pitched cry, and a blood glucose of 35 mg/dL. What is the priority action?
A. Reassess blood glucose in 1 hour
B. Notify the provider immediately
C. Initiate breastfeeding or formula feeding
D. Swaddle and monitor closely
, Correct Answer: C. Initiate breastfeeding or formula feeding
Rationale: This is neonatal hypoglycemia, which must be treated immediately to
prevent neurologic damage. Feeding is the first-line intervention. A glucose <40 in
symptomatic newborns requires urgent action.
6. A client is receiving oxytocin to induce labor. Which finding requires immediate
discontinuation of the infusion?
A. Contractions every 3 minutes
B. Fetal heart rate of 170 bpm
C. Uterine contractions lasting 120 seconds
D. Client complains of back pain
Correct Answer: C. Uterine contractions lasting 120 seconds
Rationale: Prolonged contractions (>90 seconds) indicate uterine
hyperstimulation, risking uterine rupture and fetal distress. Oxytocin should be
stopped immediately. A FHR of 170 is mild tachycardia; back pain is common.
7. A nurse is providing discharge instructions to a client with a cesarean delivery.
Which statement indicates the need for further teaching?
