NCLEX RN Maternal Newborn Nursing
Exam 3 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026
1. A pregnant 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. Preterm labor
Answer: Placenta previa
Rationale: Placenta previa occurs when the placenta partially or completely
covers the cervical opening and typically causes painless, bright-red vaginal
bleeding. Digital vaginal examinations should be avoided until placenta
previa is ruled out.
2. A client with severe preeclampsia is receiving magnesium sulfate. Which
finding requires immediate nursing intervention?
A. Respiratory rate of 10/min
B. Urine output of 40 mL/hr
C. Blood pressure of 150/96 mm Hg
D. Patellar reflexes 2+
Answer: Respiratory rate of 10/min
Rationale: Magnesium sulfate toxicity can cause respiratory depression. A
respiratory rate below 12/min requires immediate intervention, including
,stopping the infusion and preparing to administer calcium gluconate as
prescribed.
3. Which finding is most concerning in a newborn 2 hours after birth?
A. Acrocyanosis
B. Respiratory rate of 42/min
C. Heart rate of 140/min
D. Grunting and nasal flaring
Answer: Grunting and nasal flaring
Rationale: Grunting and nasal flaring are signs of respiratory distress in a
newborn and require prompt assessment and intervention. Acrocyanosis is
common shortly after birth.
4. A postpartum client has a boggy uterus and heavy vaginal bleeding.
What should the nurse do first?
A. Notify the healthcare provider
B. Administer oxytocin
C. Massage the uterine fundus
D. Obtain a hemoglobin level
Answer: Massage the uterine fundus
Rationale: A boggy uterus indicates uterine atony, a common cause of
postpartum hemorrhage. Fundal massage stimulates uterine contraction and
is the initial nursing intervention.
5. Which assessment finding is expected in a healthy newborn during the
first 24 hours?
A. Central cyanosis
B. Respiratory rate of 40/min
C. Persistent grunting
D. Temperature of 35°C (95°F)
,Answer: Respiratory rate of 40/min
Rationale: A normal newborn respiratory rate is approximately 30–60
breaths/min. Central cyanosis, persistent grunting, and significant
hypothermia are abnormal findings.
6. A pregnant client asks why folic acid is important during pregnancy.
What is the best response?
A. It prevents gestational diabetes.
B. It prevents neural tube defects.
C. It prevents postpartum hemorrhage.
D. It prevents Rh incompatibility.
Answer: It prevents neural tube defects.
Rationale: Adequate folic acid before conception and during early pregnancy
decreases the risk of fetal neural tube defects such as spina bifida.
7. Which finding is characteristic of 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 is premature separation of the placenta and
commonly presents with painful vaginal bleeding, uterine tenderness, and a
rigid or boardlike abdomen.
8. A newborn is receiving phototherapy for hyperbilirubinemia. Which
intervention is appropriate?
A. Keep the newborn fully clothed.
B. Cover the newborn's eyes.
, C. Apply lotion to the skin every 2 hours.
D. Stop feedings during phototherapy.
Answer: Cover the newborn's eyes.
Rationale: Eye protection is necessary during phototherapy to prevent retinal
injury. The newborn should have maximum skin exposure and receive
adequate feeding and hydration.
9. A client at 34 weeks' gestation reports regular uterine contractions every
5 minutes. Which additional finding supports a diagnosis of preterm
labor?
A. Cervical dilation and effacement
B. Increased appetite
C. Mild dependent edema
D. Occasional Braxton Hicks contractions
Answer: Cervical dilation and effacement
Rationale: Preterm labor involves regular uterine contractions accompanied
by progressive cervical change before 37 weeks' gestation.
10.Which medication should the nurse anticipate administering to a
pregnant client experiencing preterm labor to accelerate fetal lung
maturity?
A. Oxytocin
B. Betamethasone
C. Methylergonovine
D. Magnesium hydroxide
Answer: Betamethasone
Rationale: Antenatal corticosteroids such as betamethasone promote fetal
lung maturity and reduce complications associated with preterm birth.
Exam 3 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026
1. A pregnant 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. Preterm labor
Answer: Placenta previa
Rationale: Placenta previa occurs when the placenta partially or completely
covers the cervical opening and typically causes painless, bright-red vaginal
bleeding. Digital vaginal examinations should be avoided until placenta
previa is ruled out.
2. A client with severe preeclampsia is receiving magnesium sulfate. Which
finding requires immediate nursing intervention?
A. Respiratory rate of 10/min
B. Urine output of 40 mL/hr
C. Blood pressure of 150/96 mm Hg
D. Patellar reflexes 2+
Answer: Respiratory rate of 10/min
Rationale: Magnesium sulfate toxicity can cause respiratory depression. A
respiratory rate below 12/min requires immediate intervention, including
,stopping the infusion and preparing to administer calcium gluconate as
prescribed.
3. Which finding is most concerning in a newborn 2 hours after birth?
A. Acrocyanosis
B. Respiratory rate of 42/min
C. Heart rate of 140/min
D. Grunting and nasal flaring
Answer: Grunting and nasal flaring
Rationale: Grunting and nasal flaring are signs of respiratory distress in a
newborn and require prompt assessment and intervention. Acrocyanosis is
common shortly after birth.
4. A postpartum client has a boggy uterus and heavy vaginal bleeding.
What should the nurse do first?
A. Notify the healthcare provider
B. Administer oxytocin
C. Massage the uterine fundus
D. Obtain a hemoglobin level
Answer: Massage the uterine fundus
Rationale: A boggy uterus indicates uterine atony, a common cause of
postpartum hemorrhage. Fundal massage stimulates uterine contraction and
is the initial nursing intervention.
5. Which assessment finding is expected in a healthy newborn during the
first 24 hours?
A. Central cyanosis
B. Respiratory rate of 40/min
C. Persistent grunting
D. Temperature of 35°C (95°F)
,Answer: Respiratory rate of 40/min
Rationale: A normal newborn respiratory rate is approximately 30–60
breaths/min. Central cyanosis, persistent grunting, and significant
hypothermia are abnormal findings.
6. A pregnant client asks why folic acid is important during pregnancy.
What is the best response?
A. It prevents gestational diabetes.
B. It prevents neural tube defects.
C. It prevents postpartum hemorrhage.
D. It prevents Rh incompatibility.
Answer: It prevents neural tube defects.
Rationale: Adequate folic acid before conception and during early pregnancy
decreases the risk of fetal neural tube defects such as spina bifida.
7. Which finding is characteristic of 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 is premature separation of the placenta and
commonly presents with painful vaginal bleeding, uterine tenderness, and a
rigid or boardlike abdomen.
8. A newborn is receiving phototherapy for hyperbilirubinemia. Which
intervention is appropriate?
A. Keep the newborn fully clothed.
B. Cover the newborn's eyes.
, C. Apply lotion to the skin every 2 hours.
D. Stop feedings during phototherapy.
Answer: Cover the newborn's eyes.
Rationale: Eye protection is necessary during phototherapy to prevent retinal
injury. The newborn should have maximum skin exposure and receive
adequate feeding and hydration.
9. A client at 34 weeks' gestation reports regular uterine contractions every
5 minutes. Which additional finding supports a diagnosis of preterm
labor?
A. Cervical dilation and effacement
B. Increased appetite
C. Mild dependent edema
D. Occasional Braxton Hicks contractions
Answer: Cervical dilation and effacement
Rationale: Preterm labor involves regular uterine contractions accompanied
by progressive cervical change before 37 weeks' gestation.
10.Which medication should the nurse anticipate administering to a
pregnant client experiencing preterm labor to accelerate fetal lung
maturity?
A. Oxytocin
B. Betamethasone
C. Methylergonovine
D. Magnesium hydroxide
Answer: Betamethasone
Rationale: Antenatal corticosteroids such as betamethasone promote fetal
lung maturity and reduce complications associated with preterm birth.
