BSN Maternal-Newborn Nursing Exam 2 Practice UPDATED
ACTUAL Questions and CORRECT Answers
1. A nurse is assessing a client 2 hours postpartum and finds the fundus is boggy
and shifted to the right. What is the priority nursing action?
A. Administer oxytocin as ordered
B. Assist the client to the bathroom to void
C. Massage the fundus until firm
D. Notify the healthcare provider immediately
Answer: B
Rationale: A fundus shifted to the right usually indicates a distended bladder, which can
prevent the uterus from contracting. Emptying the bladder is the priority to allow the
fundus to return to the midline and firm up.
2. Which of the following is a normal finding for lochia on the second day
postpartum?
A. Lochia serosa
B. Lochia rubra
C. Lochia alba
D. Lochia containing large clots
Answer: B
Rationale: Lochia rubra is the dark red discharge occurring for the first 1-3 days after
delivery. Lochia serosa occurs from days 4-10, and lochia alba follows.
,3. A nurse is caring for a client receiving Magnesium Sulfate for pre-eclampsia.
Which finding should the nurse report as a sign of toxicity?
A. Respiratory rate of 10 breaths/min
B. Deep tendon reflexes of 2+
C. Urinary output of 40 mL/hr
D. Serum magnesium level of 6 mg/dL
Answer: A
Rationale: Magnesium sulfate is a CNS depressant. Signs of toxicity include a respiratory
rate less than 12, loss of deep tendon reflexes, and decreased urinary output. A therapeutic
magnesium level is 4-7 mg/dL.
4. A newborn has a heart rate of 110, a slow/irregular respiratory effort, some
flexion of extremities, a grimace during suctioning, and a pink body with blue
extremities. What is the APGAR score?
A. 5
B. 8
C. 7
D. 6
Answer: D
Rationale: HR > 100 (2), Slow resp (1), Some flexion (1), Grimace (1), Acrocyanosis (1).
Total = 6.
5. To prevent heat loss through evaporation in a newborn, which action should
the nurse take?
A. Dry the infant thoroughly immediately after birth
B. Keep the infant away from air conditioner vents
C. Place the infant on a pre-warmed radiant warmer
D. Warm the stethoscope before touching the infant
Answer: A
, Rationale: Evaporation occurs when moisture on the skin is converted to vapor. Drying
the infant immediately removes the moisture and prevents this type of heat loss.
6. A postpartum client is concerned about a ‘gush’ of blood from the vagina
when she stands up for the first time. What is the nurse’s best response?
A. Blood pools in the vagina while lying down and flows out when standing
B. This is a sign of late postpartum hemorrhage
C. You must have a cervical laceration that needs repair
D. Stay in bed until the doctor can examine you
Answer: A
Rationale: Gravity causes lochia to pool in the vagina while the client is supine; standing
up causes the pooled blood to flow out, which is a normal finding.
7. Which medication is the antidote for Magnesium Sulfate toxicity?
A. Naloxone
B. Oxytocin
C. Terbutaline
D. Calcium Gluconate
Answer: D
Rationale: Calcium Gluconate is the specific antagonist for magnesium sulfate and should
be readily available at the bedside.
8. A nurse is assessing a newborn and notes a swelling on the head that does
not cross the suture lines. How should the nurse document this?
A. Caput succedaneum
B. Cephalohematoma
C. Molding
D. Encephalocele
Answer: B
ACTUAL Questions and CORRECT Answers
1. A nurse is assessing a client 2 hours postpartum and finds the fundus is boggy
and shifted to the right. What is the priority nursing action?
A. Administer oxytocin as ordered
B. Assist the client to the bathroom to void
C. Massage the fundus until firm
D. Notify the healthcare provider immediately
Answer: B
Rationale: A fundus shifted to the right usually indicates a distended bladder, which can
prevent the uterus from contracting. Emptying the bladder is the priority to allow the
fundus to return to the midline and firm up.
2. Which of the following is a normal finding for lochia on the second day
postpartum?
A. Lochia serosa
B. Lochia rubra
C. Lochia alba
D. Lochia containing large clots
Answer: B
Rationale: Lochia rubra is the dark red discharge occurring for the first 1-3 days after
delivery. Lochia serosa occurs from days 4-10, and lochia alba follows.
,3. A nurse is caring for a client receiving Magnesium Sulfate for pre-eclampsia.
Which finding should the nurse report as a sign of toxicity?
A. Respiratory rate of 10 breaths/min
B. Deep tendon reflexes of 2+
C. Urinary output of 40 mL/hr
D. Serum magnesium level of 6 mg/dL
Answer: A
Rationale: Magnesium sulfate is a CNS depressant. Signs of toxicity include a respiratory
rate less than 12, loss of deep tendon reflexes, and decreased urinary output. A therapeutic
magnesium level is 4-7 mg/dL.
4. A newborn has a heart rate of 110, a slow/irregular respiratory effort, some
flexion of extremities, a grimace during suctioning, and a pink body with blue
extremities. What is the APGAR score?
A. 5
B. 8
C. 7
D. 6
Answer: D
Rationale: HR > 100 (2), Slow resp (1), Some flexion (1), Grimace (1), Acrocyanosis (1).
Total = 6.
5. To prevent heat loss through evaporation in a newborn, which action should
the nurse take?
A. Dry the infant thoroughly immediately after birth
B. Keep the infant away from air conditioner vents
C. Place the infant on a pre-warmed radiant warmer
D. Warm the stethoscope before touching the infant
Answer: A
, Rationale: Evaporation occurs when moisture on the skin is converted to vapor. Drying
the infant immediately removes the moisture and prevents this type of heat loss.
6. A postpartum client is concerned about a ‘gush’ of blood from the vagina
when she stands up for the first time. What is the nurse’s best response?
A. Blood pools in the vagina while lying down and flows out when standing
B. This is a sign of late postpartum hemorrhage
C. You must have a cervical laceration that needs repair
D. Stay in bed until the doctor can examine you
Answer: A
Rationale: Gravity causes lochia to pool in the vagina while the client is supine; standing
up causes the pooled blood to flow out, which is a normal finding.
7. Which medication is the antidote for Magnesium Sulfate toxicity?
A. Naloxone
B. Oxytocin
C. Terbutaline
D. Calcium Gluconate
Answer: D
Rationale: Calcium Gluconate is the specific antagonist for magnesium sulfate and should
be readily available at the bedside.
8. A nurse is assessing a newborn and notes a swelling on the head that does
not cross the suture lines. How should the nurse document this?
A. Caput succedaneum
B. Cephalohematoma
C. Molding
D. Encephalocele
Answer: B
