Nursing Q&A | Maternal-Child Nursing
1. A nurse is teaching a primigravida about signs of true labor. Which sign
indicates true labor?
A) Irregular contractions that subside with walking
B) Contractions that increase in intensity and frequency
C) Bloody show only
D) Rupture of membranes before contractions
Correct Answer: Contractions that increase in intensity and frequency
Rationale: True labor is characterized by regular contractions that become
stronger, longer, and closer together, leading to progressive cervical change.
Braxton Hicks contractions are irregular and often stop with activity. Bloody
show alone or rupture of membranes does not confirm true labor without
progressive contractions.
2. A client at 38 weeks' gestation reports a sudden gush of fluid from the
vagina. Which action should the nurse take first?
A) Check cervical dilation
B) Assess fetal heart rate
C) Test the fluid with nitrazine paper
D) Ask the client to void
Correct Answer: Test the fluid with nitrazine paper
Rationale: Nitrazine paper turns blue (alkaline) in the presence of amniotic
fluid, confirming rupture of membranes. This is the priority to determine if
the fluid is amniotic fluid versus urine or vaginal discharge. After confirming
ROM, the nurse should assess fetal heart rate.
,3. A client's expected date of delivery (EDD) by last menstrual period (LMP)
is July 20. Using Naegele's rule, what was her LMP?
A) October 13
B) October 27
C) November 13
D) November 27
Correct Answer: October 13
Rationale: Naegele's rule calculates EDD by subtracting 3 months from the
first day of the LMP and adding 7 days. Working backward: July 20 minus 7
days = July 13, plus 3 months = October 13. Therefore, the LMP was October
13 of the previous year.
4. Which of the following is considered a positive sign of pregnancy?
A) Goodell's sign
B) Positive hCG test
C) Fetal heartbeat on Doppler
D) Chadwick's sign
Correct Answer: Fetal heartbeat on Doppler
Rationale: Positive signs of pregnancy definitively confirm the presence of a
fetus. These include hearing a fetal heartbeat, palpating fetal movement,
and visualizing the fetus on ultrasound. Goodell's sign, positive hCG, and
Chadwick's sign are probable signs of pregnancy.
,5. A client at 10 weeks' gestation is diagnosed with hyperemesis gravidarum.
Which complication should the nurse prioritize?
A) Dehydration and electrolyte imbalance
B) Gestational hypertension
C) Preterm labor
D) Abruptio placentae
Correct Answer: Dehydration and electrolyte imbalance
Rationale: Hyperemesis gravidarum involves severe, persistent vomiting
leading to dehydration, electrolyte imbalances, ketosis, and weight loss. This
is the priority complication to address. Hypertension, preterm labor, and
abruptio placentae are not direct complications of hyperemesis.
6. At 20 weeks' gestation, the fundal height should be at which location?
A) Symphysis pubis
B) Umbilicus
C) Xiphoid process
D) Halfway between the umbilicus and xiphoid process
Correct Answer: Umbilicus
Rationale: Fundal height in centimeters typically corresponds to weeks of
gestation. At 20 weeks, the fundus should be at the level of the umbilicus. At
12 weeks it is at the symphysis pubis, and by 36 weeks it reaches the
xiphoid process.
7. A nurse is performing Leopold maneuvers on a client at 36 weeks'
gestation. What is the primary purpose of this assessment?
, A) Determine fetal lie, presentation, and position
B) Measure contraction frequency
C) Assess cervical dilation
D) Check amniotic fluid index
Correct Answer: Determine fetal lie, presentation, and position
Rationale: Leopold maneuvers are a systematic method of abdominal
palpation used to determine the fetal lie (longitudinal or transverse),
presentation (cephalic or breech), and position (e.g., occiput anterior or
posterior). This information guides labor management and delivery planning.
8. A nurse is calculating the Apgar score for a newborn at 1 minute of life.
The newborn has a heart rate of 80 bpm, weak cry, some flexion, grimace,
and acrocyanosis. What is the Apgar score?
A) 4
B) 5
C) 6
D) 7
Correct Answer: 5
Rationale: Apgar scoring: Heart rate <100 = 1, weak cry = 1, some flexion =
1, grimace = 1, acrocyanosis = 1. Total = 5. A score of 4-6 indicates
moderate difficulty; the infant may need stimulation and oxygen. Scores of 7-
10 indicate a vigorous newborn.
9. A nurse is reviewing fetal heart rate patterns. Late decelerations are most
commonly associated with which condition?
A) Cord compression