Test Bank for Maternity and Pediatric Nursing
5th Edition Ricci Kyle Carman | All 51 Chapters
| Verified Answers & Rationales | 2025/2026
NCLEX Prep A+
,1. A nurse is assessing a pregnant client at 12 weeks' gestation. Which finding should the
nurse report to the provider?
A. Morning sickness
B. Breast tenderness
C. Vaginal bleeding with cramping
D. Urinary frequency
Rationale: Vaginal bleeding with cramping during the first trimester may indicate a miscarriage
or ectopic pregnancy and requires immediate evaluation. Morning sickness, breast tenderness,
and urinary frequency are normal physiological changes of pregnancy.
2. A nurse is teaching a prenatal client about folic acid supplementation. Which statement
indicates understanding?
A. "I should take folic acid only during the third trimester."
B. "I should take 400 mcg of folic acid daily before and during early pregnancy."
C. "Folic acid prevents all birth defects."
D. "I only need folic acid if I have a history of anemia."
Rationale: Folic acid 400 mcg daily is recommended before conception and during early
pregnancy to reduce the risk of neural tube defects. It does not prevent all birth defects and is
not limited to the third trimester.
3. A client at 36 weeks' gestation reports a sudden gush of fluid from the vagina. What is the
nurse's priority action?
A. Perform a sterile vaginal exam
B. Assess the fetal heart rate and check for cord prolapse
C. Ask the client to ambulate to promote labor
D. Document the finding and notify the provider in the morning
Rationale: Rupture of membranes at 36 weeks requires immediate assessment for cord
prolapse, which is an emergency. A sterile vaginal exam may be performed after assessing for
cord prolapse, but fetal heart rate assessment is the priority.
4. A nurse is caring for a client in the first stage of labor. Which finding indicates a
complication?
A. Contractions every 3 minutes lasting 60 seconds
B. Fetal heart rate of 90 beats per minute sustained for 10 minutes
,C. Cervical dilation from 4 cm to 6 cm
D. Client reports increasing pelvic pressure
Rationale: A sustained fetal heart rate below 110 beats per minute indicates fetal bradycardia,
which is a complication requiring intervention. The other findings are expected during the first
stage of labor.
5. A postpartum client is experiencing heavy vaginal bleeding. Which action should the nurse
take first?
A. Administer oxytocin as ordered
B. Massage the uterine fundus
C. Perform a perineal pad count
D. Notify the provider
Rationale: Uterine atony is the most common cause of postpartum hemorrhage. Fundal
massage is the first intervention to stimulate uterine contraction and control bleeding.
6. A nurse is assessing a newborn immediately after delivery. Which finding requires
immediate intervention?
A. Heart rate of 140 beats per minute
B. Respiratory rate of 80 breaths per minute with grunting
C. Birth weight of 3.2 kg
D. Vernix caseosa on the skin
Rationale: A respiratory rate above 60 with grunting indicates respiratory distress in a newborn
and requires immediate intervention. The other findings are normal.
7. A nurse is teaching a postpartum client about breastfeeding. Which statement indicates a
need for further teaching?
A. "I should feed my baby every 2 to 3 hours."
B. "I should ensure a good latch to prevent sore nipples."
C. "I should supplement with formula if my baby seems hungry after feeding."
D. "I should drink plenty of fluids while breastfeeding."
Rationale: Supplementing with formula can interfere with milk supply and breastfeeding
success. Newborns should be breastfed on demand, and supplementation should only be done if
medically indicated.
, 8. A nurse is caring for a child with acute otitis media. Which finding is expected?
A. Ear pain and pulling at the ear
B. Clear drainage from the ear
C. Decreased temperature
D. Improved hearing
Rationale: Acute otitis media presents with ear pain, fever, and pulling at the ear. Clear drainage
may indicate otitis externa, and hearing is typically decreased due to fluid accumulation.
9. A nurse is assessing a child with suspected meningitis. Which finding is most concerning?
A. Fever of 101°F (38.3°C)
B. Petechial rash and nuchal rigidity
C. Headache
D. Vomiting
Rationale: Petechial rash and nuchal rigidity are classic signs of meningococcal meningitis,
which is a medical emergency. Fever, headache, and vomiting are also signs but less specific.
10. A nurse is teaching parents about injury prevention for a toddler. Which statement
indicates understanding?
A. "I can leave my child unattended in the bathtub for a few minutes."
B. "I should place safety gates at the top and bottom of stairs."
C. "I should keep cleaning supplies under the sink for easy access."
D. "My child can ride a bike without a helmet if supervised."
Rationale: Safety gates at stairs prevent falls, a leading cause of injury in toddlers. Children
should never be left unattended in water, cleaning supplies should be locked away, and helmets
should always be worn.
11. A nurse is caring for a client at 28 weeks' gestation who reports decreased fetal
movement. What is the priority action?
A. Reassure the client that decreased movement is normal
B. Perform a nonstress test
C. Schedule a follow-up appointment in one week
D. Ask the client to drink orange juice and lie on her left side
5th Edition Ricci Kyle Carman | All 51 Chapters
| Verified Answers & Rationales | 2025/2026
NCLEX Prep A+
,1. A nurse is assessing a pregnant client at 12 weeks' gestation. Which finding should the
nurse report to the provider?
A. Morning sickness
B. Breast tenderness
C. Vaginal bleeding with cramping
D. Urinary frequency
Rationale: Vaginal bleeding with cramping during the first trimester may indicate a miscarriage
or ectopic pregnancy and requires immediate evaluation. Morning sickness, breast tenderness,
and urinary frequency are normal physiological changes of pregnancy.
2. A nurse is teaching a prenatal client about folic acid supplementation. Which statement
indicates understanding?
A. "I should take folic acid only during the third trimester."
B. "I should take 400 mcg of folic acid daily before and during early pregnancy."
C. "Folic acid prevents all birth defects."
D. "I only need folic acid if I have a history of anemia."
Rationale: Folic acid 400 mcg daily is recommended before conception and during early
pregnancy to reduce the risk of neural tube defects. It does not prevent all birth defects and is
not limited to the third trimester.
3. A client at 36 weeks' gestation reports a sudden gush of fluid from the vagina. What is the
nurse's priority action?
A. Perform a sterile vaginal exam
B. Assess the fetal heart rate and check for cord prolapse
C. Ask the client to ambulate to promote labor
D. Document the finding and notify the provider in the morning
Rationale: Rupture of membranes at 36 weeks requires immediate assessment for cord
prolapse, which is an emergency. A sterile vaginal exam may be performed after assessing for
cord prolapse, but fetal heart rate assessment is the priority.
4. A nurse is caring for a client in the first stage of labor. Which finding indicates a
complication?
A. Contractions every 3 minutes lasting 60 seconds
B. Fetal heart rate of 90 beats per minute sustained for 10 minutes
,C. Cervical dilation from 4 cm to 6 cm
D. Client reports increasing pelvic pressure
Rationale: A sustained fetal heart rate below 110 beats per minute indicates fetal bradycardia,
which is a complication requiring intervention. The other findings are expected during the first
stage of labor.
5. A postpartum client is experiencing heavy vaginal bleeding. Which action should the nurse
take first?
A. Administer oxytocin as ordered
B. Massage the uterine fundus
C. Perform a perineal pad count
D. Notify the provider
Rationale: Uterine atony is the most common cause of postpartum hemorrhage. Fundal
massage is the first intervention to stimulate uterine contraction and control bleeding.
6. A nurse is assessing a newborn immediately after delivery. Which finding requires
immediate intervention?
A. Heart rate of 140 beats per minute
B. Respiratory rate of 80 breaths per minute with grunting
C. Birth weight of 3.2 kg
D. Vernix caseosa on the skin
Rationale: A respiratory rate above 60 with grunting indicates respiratory distress in a newborn
and requires immediate intervention. The other findings are normal.
7. A nurse is teaching a postpartum client about breastfeeding. Which statement indicates a
need for further teaching?
A. "I should feed my baby every 2 to 3 hours."
B. "I should ensure a good latch to prevent sore nipples."
C. "I should supplement with formula if my baby seems hungry after feeding."
D. "I should drink plenty of fluids while breastfeeding."
Rationale: Supplementing with formula can interfere with milk supply and breastfeeding
success. Newborns should be breastfed on demand, and supplementation should only be done if
medically indicated.
, 8. A nurse is caring for a child with acute otitis media. Which finding is expected?
A. Ear pain and pulling at the ear
B. Clear drainage from the ear
C. Decreased temperature
D. Improved hearing
Rationale: Acute otitis media presents with ear pain, fever, and pulling at the ear. Clear drainage
may indicate otitis externa, and hearing is typically decreased due to fluid accumulation.
9. A nurse is assessing a child with suspected meningitis. Which finding is most concerning?
A. Fever of 101°F (38.3°C)
B. Petechial rash and nuchal rigidity
C. Headache
D. Vomiting
Rationale: Petechial rash and nuchal rigidity are classic signs of meningococcal meningitis,
which is a medical emergency. Fever, headache, and vomiting are also signs but less specific.
10. A nurse is teaching parents about injury prevention for a toddler. Which statement
indicates understanding?
A. "I can leave my child unattended in the bathtub for a few minutes."
B. "I should place safety gates at the top and bottom of stairs."
C. "I should keep cleaning supplies under the sink for easy access."
D. "My child can ride a bike without a helmet if supervised."
Rationale: Safety gates at stairs prevent falls, a leading cause of injury in toddlers. Children
should never be left unattended in water, cleaning supplies should be locked away, and helmets
should always be worn.
11. A nurse is caring for a client at 28 weeks' gestation who reports decreased fetal
movement. What is the priority action?
A. Reassure the client that decreased movement is normal
B. Perform a nonstress test
C. Schedule a follow-up appointment in one week
D. Ask the client to drink orange juice and lie on her left side
