NCLEX RN Maternal Newborn Nursing
Exam 1 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026
1. A pregnant client at 10 weeks' gestation asks the nurse when the fetal
heart can usually first be detected by Doppler. Which response is most
appropriate?
A. 6 weeks
B. 8 weeks
C. 10–12 weeks
D. 18–20 weeks
Answer: 10–12 weeks
Rationale: Fetal heart tones can commonly be detected by Doppler around
10–12 weeks of gestation. Earlier detection may require ultrasound.
2. A client at 28 weeks' gestation reports painless, bright-red vaginal
bleeding. Which condition should the nurse suspect?
A. Abruptio placentae
B. Placenta previa
C. Ectopic pregnancy
D. Spontaneous abortion
Answer: Placenta previa
Rationale: Placenta previa classically causes painless, bright-red vaginal
bleeding during the second half of pregnancy. Digital vaginal examinations
should be avoided until placenta previa is excluded.
, 3. A pregnant client with severe preeclampsia is receiving magnesium
sulfate. Which finding requires immediate nursing intervention?
A. Respiratory rate of 10/min
B. Urine output of 45 mL/hr
C. Patellar reflexes 2+
D. Blood pressure of 150/96 mm Hg
Answer: Respiratory rate of 10/min
Rationale: Magnesium sulfate can cause respiratory depression when toxicity
develops. A respiratory rate below 12/min is concerning and requires
immediate intervention.
4. Which medication should the nurse keep available for a client receiving
magnesium sulfate who develops toxicity?
A. Naloxone
B. Calcium gluconate
C. Protamine sulfate
D. Vitamin K
Answer: Calcium gluconate
Rationale: Calcium gluconate is the antidote for magnesium sulfate toxicity
and should be readily available during therapy.
5. A nurse is assessing a client in labor. Which finding indicates true labor?
A. Contractions decrease with ambulation
B. Contractions remain irregular
C. Cervical dilation and effacement occur
D. Discomfort is relieved by hydration
Answer: Cervical dilation and effacement occur
,Rationale: True labor produces progressive cervical dilation and effacement
along with regular contractions that generally increase in frequency,
duration, and intensity.
6. A client receiving oxytocin has contractions every 1 minute lasting 100
seconds. Which action should the nurse take first?
A. Increase the oxytocin rate
B. Place the client supine
C. Stop the oxytocin infusion
D. Encourage the client to push
Answer: Stop the oxytocin infusion
Rationale: Excessive uterine activity can compromise fetal oxygenation. The
oxytocin infusion should be stopped immediately, followed by intrauterine
resuscitation measures as indicated.
7. The nurse is reviewing a fetal heart rate tracing. Which finding is most
reassuring?
A. Late decelerations
B. Variable decelerations
C. Moderate variability
D. Absent variability
Answer: Moderate variability
Rationale: Moderate fetal heart rate variability is a reassuring indicator of
intact fetal autonomic function and adequate oxygenation.
8. A laboring client develops recurrent late fetal heart rate decelerations.
What is the nurse's priority intervention?
A. Place the client in a lateral position
B. Encourage pushing
, C. Increase oxytocin
D. Place the client supine
Answer: Place the client in a lateral position
Rationale: Lateral positioning improves uteroplacental perfusion and is an
immediate intervention for recurrent late decelerations. Oxytocin should also
be discontinued if it is contributing to uterine tachysystole.
9. Which assessment finding is most consistent with abruptio placentae?
A. Painless vaginal bleeding
B. Rigid, tender abdomen
C. Soft, nontender uterus
D. Bleeding without abdominal pain
Answer: Rigid, tender abdomen
Rationale: Abruptio placentae commonly presents with painful vaginal
bleeding, uterine tenderness, and a firm or rigid abdomen.
10.Which instruction should the nurse provide to a pregnant client taking
iron supplements?
A. Take iron with milk
B. Take iron with orange juice
C. Take iron with an antacid
D. Stop the medication if stools become dark
Answer: Take iron with orange juice
Rationale: Vitamin C enhances iron absorption. Iron can cause dark stools,
which are an expected effect and do not usually indicate gastrointestinal
bleeding.
11.A client at 32 weeks' gestation reports severe headache, blurred vision,
and epigastric pain. Which condition should the nurse suspect?
Exam 1 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026
1. A pregnant client at 10 weeks' gestation asks the nurse when the fetal
heart can usually first be detected by Doppler. Which response is most
appropriate?
A. 6 weeks
B. 8 weeks
C. 10–12 weeks
D. 18–20 weeks
Answer: 10–12 weeks
Rationale: Fetal heart tones can commonly be detected by Doppler around
10–12 weeks of gestation. Earlier detection may require ultrasound.
2. A client at 28 weeks' gestation reports painless, bright-red vaginal
bleeding. Which condition should the nurse suspect?
A. Abruptio placentae
B. Placenta previa
C. Ectopic pregnancy
D. Spontaneous abortion
Answer: Placenta previa
Rationale: Placenta previa classically causes painless, bright-red vaginal
bleeding during the second half of pregnancy. Digital vaginal examinations
should be avoided until placenta previa is excluded.
, 3. A pregnant client with severe preeclampsia is receiving magnesium
sulfate. Which finding requires immediate nursing intervention?
A. Respiratory rate of 10/min
B. Urine output of 45 mL/hr
C. Patellar reflexes 2+
D. Blood pressure of 150/96 mm Hg
Answer: Respiratory rate of 10/min
Rationale: Magnesium sulfate can cause respiratory depression when toxicity
develops. A respiratory rate below 12/min is concerning and requires
immediate intervention.
4. Which medication should the nurse keep available for a client receiving
magnesium sulfate who develops toxicity?
A. Naloxone
B. Calcium gluconate
C. Protamine sulfate
D. Vitamin K
Answer: Calcium gluconate
Rationale: Calcium gluconate is the antidote for magnesium sulfate toxicity
and should be readily available during therapy.
5. A nurse is assessing a client in labor. Which finding indicates true labor?
A. Contractions decrease with ambulation
B. Contractions remain irregular
C. Cervical dilation and effacement occur
D. Discomfort is relieved by hydration
Answer: Cervical dilation and effacement occur
,Rationale: True labor produces progressive cervical dilation and effacement
along with regular contractions that generally increase in frequency,
duration, and intensity.
6. A client receiving oxytocin has contractions every 1 minute lasting 100
seconds. Which action should the nurse take first?
A. Increase the oxytocin rate
B. Place the client supine
C. Stop the oxytocin infusion
D. Encourage the client to push
Answer: Stop the oxytocin infusion
Rationale: Excessive uterine activity can compromise fetal oxygenation. The
oxytocin infusion should be stopped immediately, followed by intrauterine
resuscitation measures as indicated.
7. The nurse is reviewing a fetal heart rate tracing. Which finding is most
reassuring?
A. Late decelerations
B. Variable decelerations
C. Moderate variability
D. Absent variability
Answer: Moderate variability
Rationale: Moderate fetal heart rate variability is a reassuring indicator of
intact fetal autonomic function and adequate oxygenation.
8. A laboring client develops recurrent late fetal heart rate decelerations.
What is the nurse's priority intervention?
A. Place the client in a lateral position
B. Encourage pushing
, C. Increase oxytocin
D. Place the client supine
Answer: Place the client in a lateral position
Rationale: Lateral positioning improves uteroplacental perfusion and is an
immediate intervention for recurrent late decelerations. Oxytocin should also
be discontinued if it is contributing to uterine tachysystole.
9. Which assessment finding is most consistent with abruptio placentae?
A. Painless vaginal bleeding
B. Rigid, tender abdomen
C. Soft, nontender uterus
D. Bleeding without abdominal pain
Answer: Rigid, tender abdomen
Rationale: Abruptio placentae commonly presents with painful vaginal
bleeding, uterine tenderness, and a firm or rigid abdomen.
10.Which instruction should the nurse provide to a pregnant client taking
iron supplements?
A. Take iron with milk
B. Take iron with orange juice
C. Take iron with an antacid
D. Stop the medication if stools become dark
Answer: Take iron with orange juice
Rationale: Vitamin C enhances iron absorption. Iron can cause dark stools,
which are an expected effect and do not usually indicate gastrointestinal
bleeding.
11.A client at 32 weeks' gestation reports severe headache, blurred vision,
and epigastric pain. Which condition should the nurse suspect?
