Maternal Child Nursing Care 2026/2027 | Maternal Child Nursing Study
Guide, Maternal-Newborn and Pediatric Nursing Exam Prep, Practice
Questions with Answers & Rationales, Pregnancy, Prenatal Care, Labor &
Delivery, Postpartum Nursing, Newborn Assessment, Growth &
Development, Pediatric Assessment, Family-Centered Care, Maternal
Complications, Newborn Disorders, Pediatric Disorders, Medication Safety &
NCLEX-RN Review
Question 1: A nurse is assessing a client at 32 weeks gestation who reports a
sudden, severe headache and visual disturbances. Which action should the
nurse prioritize?
A. Administer acetaminophen for pain relief
B. Check blood pressure and assess for proteinuria
C. Encourage the client to rest in a left lateral position
D. Document the findings and schedule a follow-up appointment
CORRECT ANSWER: B. Check blood pressure and assess for proteinuria
Rationale: Sudden severe headache and visual disturbances at 32 weeks gestation
are classic warning signs of preeclampsia. The priority nursing action is to assess
blood pressure and evaluate for proteinuria to determine the presence of a
hypertensive disorder of pregnancy. Early identification allows for timely
intervention to prevent progression to eclampsia or other severe complications .
Question 2: During the fourth stage of labor, which assessment finding requires
immediate nursing intervention?
A. Fundus firm and at the umbilicus
B. Lochia rubra with small clots
C. Perineal edema and bruising
D. Saturating a perineal pad in 15 minutes
CORRECT ANSWER: D. Saturating a perineal pad in 15 minutes
Rationale: Saturating a perineal pad in 15 minutes indicates excessive bleeding
and possible postpartum hemorrhage, which is a medical emergency. Normal
lochia rubra may contain small clots, perineal edema is expected after vaginal
birth, and a firm fundus at the umbilicus is a normal finding immediately
,postpartum. Rapid blood loss can lead to hypovolemic shock if not addressed
promptly .
Question 3: A newborn is assessed at 1 minute of life with a heart rate of 90
bpm, slow irregular respirations, some flexion of extremities, grimace to
stimulation, and pink body with blue extremities. What is the newborn's Apgar
score?
A. 4
B. 5
C. 6
D. 7
CORRECT ANSWER: B. 5
Rationale: The Apgar score assesses five criteria: heart rate (1 point for <100
bpm), respiratory effort (1 point for slow/irregular), muscle tone (1 point for
some flexion), reflex irritability (1 point for grimace), and color (1 point for
acrocyanosis). Total = 1 + 1 + 1 + 1 + 1 = 5. This score indicates the newborn
requires some assistance with transition, such as stimulation or oxygen .
Question 4: Which statement by a pregnant client at 10 weeks gestation
indicates understanding of nutritional recommendations?
A. "I will increase my caloric intake by 500 calories per day."
B. "I need to consume 600 mcg of folic acid daily to prevent neural tube defects."
C. "I should avoid all fish to prevent mercury exposure."
D. "I will limit weight gain to 15 pounds throughout pregnancy."
CORRECT ANSWER: B. "I need to consume 600 mcg of folic acid daily to prevent
neural tube defects."
Rationale: Folic acid supplementation of 400-800 mcg daily before conception and
during early pregnancy significantly reduces the risk of neural tube defects. The
recommended daily allowance during pregnancy is 600 mcg. Caloric increase of
500 calories is recommended in the second and third trimesters, not the first.
Low-mercury fish are encouraged for omega-3 fatty acids. Weight gain
recommendations vary by pre-pregnancy BMI .
,Question 5: A nurse is preparing to administer Rho(D) immune globulin to a
postpartum client. Which assessment finding is a prerequisite for
administration?
A. Mother is Rh-negative and infant is Rh-positive
B. Mother is Rh-positive and infant is Rh-negative
C. Direct Coombs test is positive in the newborn
D. Mother received RhoGAM during the current pregnancy
CORRECT ANSWER: A. Mother is Rh-negative and infant is Rh-positive
Rationale: Rho(D) immune globulin is indicated for Rh-negative mothers who
deliver an Rh-positive infant to prevent sensitization and hemolytic disease of the
newborn in future pregnancies. If the mother is already Rh-positive, the
medication is not indicated. A positive direct Coombs test in the newborn
indicates the infant's red blood cells are already coated with antibodies .
Question 6: A nurse is assessing a pregnant client at 28 weeks gestation who
reports sudden onset of severe headache, visual disturbances, and epigastric
pain. Her blood pressure is 162/104 mmHg and urine protein is 3+. Which
condition does the nurse suspect?
A. Gestational diabetes mellitus
B. Severe preeclampsia
C. Placenta previa
D. Preterm labor
CORRECT ANSWER: B. Severe preeclampsia
Rationale: Severe preeclampsia is characterized by new-onset hypertension
(systolic ≥140 or diastolic ≥90 mmHg) after 20 weeks gestation with proteinuria,
plus symptoms including severe headache, visual disturbances, epigastric pain,
and hyperreflexia. This is a medical emergency requiring immediate provider
notification and possible delivery .
Question 7: A nurse is assessing a newborn 1 minute after birth. The infant has a
heart rate of 110 bpm, irregular respiratory effort, grimaces with suctioning, has
active motion of all extremities, and is crying vigorously with a pink body and
blue extremities. What is the Apgar score?
, A. 6
B. 7
C. 8
D. 9
CORRECT ANSWER: C. 8
Rationale: The Apgar score is calculated as follows: Heart rate >100 = 2 points;
irregular respirations = 1 point; grimace = 1 point; active motion = 2 points; pink
body with blue extremities (acrocyanosis) = 1 point. Total = 8. A score of 8-10
indicates a vigorous infant requiring only routine care .
Question 8: A nurse is teaching a pregnant patient about iron supplementation
during pregnancy. Which instruction is most accurate?
A. Take iron with milk or antacids to reduce stomach upset
B. Take iron on an empty stomach with vitamin C to enhance absorption
C. Iron supplements are only needed during the first trimester
D. Constipation is an unexpected side effect that requires discontinuation
CORRECT ANSWER: B. Take iron on an empty stomach with vitamin C to
enhance absorption
Rationale: Iron is best absorbed on an empty stomach with vitamin C (e.g., orange
juice). Calcium, dairy products, and antacids inhibit absorption. Iron requirements
increase throughout pregnancy, especially in the second and third trimesters.
Constipation is an expected side effect managed with increased fluids, fiber, and
stool softeners, not discontinuation .
Question 9: A nurse is caring for a postpartum patient on day 2 after a vaginal
delivery. The patient reports heavy vaginal bleeding with large clots, and the
uterus is found to be boggy and displaced to the right. What is the nurse's
priority action?
A. Increase the IV fluid rate and notify the provider
B. Massage the fundus and encourage the patient to empty her bladder
C. Administer oxytocin and prepare for emergency hysterectomy
D. Apply ice packs to the perineum and reassess in 30 minutes
Guide, Maternal-Newborn and Pediatric Nursing Exam Prep, Practice
Questions with Answers & Rationales, Pregnancy, Prenatal Care, Labor &
Delivery, Postpartum Nursing, Newborn Assessment, Growth &
Development, Pediatric Assessment, Family-Centered Care, Maternal
Complications, Newborn Disorders, Pediatric Disorders, Medication Safety &
NCLEX-RN Review
Question 1: A nurse is assessing a client at 32 weeks gestation who reports a
sudden, severe headache and visual disturbances. Which action should the
nurse prioritize?
A. Administer acetaminophen for pain relief
B. Check blood pressure and assess for proteinuria
C. Encourage the client to rest in a left lateral position
D. Document the findings and schedule a follow-up appointment
CORRECT ANSWER: B. Check blood pressure and assess for proteinuria
Rationale: Sudden severe headache and visual disturbances at 32 weeks gestation
are classic warning signs of preeclampsia. The priority nursing action is to assess
blood pressure and evaluate for proteinuria to determine the presence of a
hypertensive disorder of pregnancy. Early identification allows for timely
intervention to prevent progression to eclampsia or other severe complications .
Question 2: During the fourth stage of labor, which assessment finding requires
immediate nursing intervention?
A. Fundus firm and at the umbilicus
B. Lochia rubra with small clots
C. Perineal edema and bruising
D. Saturating a perineal pad in 15 minutes
CORRECT ANSWER: D. Saturating a perineal pad in 15 minutes
Rationale: Saturating a perineal pad in 15 minutes indicates excessive bleeding
and possible postpartum hemorrhage, which is a medical emergency. Normal
lochia rubra may contain small clots, perineal edema is expected after vaginal
birth, and a firm fundus at the umbilicus is a normal finding immediately
,postpartum. Rapid blood loss can lead to hypovolemic shock if not addressed
promptly .
Question 3: A newborn is assessed at 1 minute of life with a heart rate of 90
bpm, slow irregular respirations, some flexion of extremities, grimace to
stimulation, and pink body with blue extremities. What is the newborn's Apgar
score?
A. 4
B. 5
C. 6
D. 7
CORRECT ANSWER: B. 5
Rationale: The Apgar score assesses five criteria: heart rate (1 point for <100
bpm), respiratory effort (1 point for slow/irregular), muscle tone (1 point for
some flexion), reflex irritability (1 point for grimace), and color (1 point for
acrocyanosis). Total = 1 + 1 + 1 + 1 + 1 = 5. This score indicates the newborn
requires some assistance with transition, such as stimulation or oxygen .
Question 4: Which statement by a pregnant client at 10 weeks gestation
indicates understanding of nutritional recommendations?
A. "I will increase my caloric intake by 500 calories per day."
B. "I need to consume 600 mcg of folic acid daily to prevent neural tube defects."
C. "I should avoid all fish to prevent mercury exposure."
D. "I will limit weight gain to 15 pounds throughout pregnancy."
CORRECT ANSWER: B. "I need to consume 600 mcg of folic acid daily to prevent
neural tube defects."
Rationale: Folic acid supplementation of 400-800 mcg daily before conception and
during early pregnancy significantly reduces the risk of neural tube defects. The
recommended daily allowance during pregnancy is 600 mcg. Caloric increase of
500 calories is recommended in the second and third trimesters, not the first.
Low-mercury fish are encouraged for omega-3 fatty acids. Weight gain
recommendations vary by pre-pregnancy BMI .
,Question 5: A nurse is preparing to administer Rho(D) immune globulin to a
postpartum client. Which assessment finding is a prerequisite for
administration?
A. Mother is Rh-negative and infant is Rh-positive
B. Mother is Rh-positive and infant is Rh-negative
C. Direct Coombs test is positive in the newborn
D. Mother received RhoGAM during the current pregnancy
CORRECT ANSWER: A. Mother is Rh-negative and infant is Rh-positive
Rationale: Rho(D) immune globulin is indicated for Rh-negative mothers who
deliver an Rh-positive infant to prevent sensitization and hemolytic disease of the
newborn in future pregnancies. If the mother is already Rh-positive, the
medication is not indicated. A positive direct Coombs test in the newborn
indicates the infant's red blood cells are already coated with antibodies .
Question 6: A nurse is assessing a pregnant client at 28 weeks gestation who
reports sudden onset of severe headache, visual disturbances, and epigastric
pain. Her blood pressure is 162/104 mmHg and urine protein is 3+. Which
condition does the nurse suspect?
A. Gestational diabetes mellitus
B. Severe preeclampsia
C. Placenta previa
D. Preterm labor
CORRECT ANSWER: B. Severe preeclampsia
Rationale: Severe preeclampsia is characterized by new-onset hypertension
(systolic ≥140 or diastolic ≥90 mmHg) after 20 weeks gestation with proteinuria,
plus symptoms including severe headache, visual disturbances, epigastric pain,
and hyperreflexia. This is a medical emergency requiring immediate provider
notification and possible delivery .
Question 7: A nurse is assessing a newborn 1 minute after birth. The infant has a
heart rate of 110 bpm, irregular respiratory effort, grimaces with suctioning, has
active motion of all extremities, and is crying vigorously with a pink body and
blue extremities. What is the Apgar score?
, A. 6
B. 7
C. 8
D. 9
CORRECT ANSWER: C. 8
Rationale: The Apgar score is calculated as follows: Heart rate >100 = 2 points;
irregular respirations = 1 point; grimace = 1 point; active motion = 2 points; pink
body with blue extremities (acrocyanosis) = 1 point. Total = 8. A score of 8-10
indicates a vigorous infant requiring only routine care .
Question 8: A nurse is teaching a pregnant patient about iron supplementation
during pregnancy. Which instruction is most accurate?
A. Take iron with milk or antacids to reduce stomach upset
B. Take iron on an empty stomach with vitamin C to enhance absorption
C. Iron supplements are only needed during the first trimester
D. Constipation is an unexpected side effect that requires discontinuation
CORRECT ANSWER: B. Take iron on an empty stomach with vitamin C to
enhance absorption
Rationale: Iron is best absorbed on an empty stomach with vitamin C (e.g., orange
juice). Calcium, dairy products, and antacids inhibit absorption. Iron requirements
increase throughout pregnancy, especially in the second and third trimesters.
Constipation is an expected side effect managed with increased fluids, fiber, and
stool softeners, not discontinuation .
Question 9: A nurse is caring for a postpartum patient on day 2 after a vaginal
delivery. The patient reports heavy vaginal bleeding with large clots, and the
uterus is found to be boggy and displaced to the right. What is the nurse's
priority action?
A. Increase the IV fluid rate and notify the provider
B. Massage the fundus and encourage the patient to empty her bladder
C. Administer oxytocin and prepare for emergency hysterectomy
D. Apply ice packs to the perineum and reassess in 30 minutes
