1. Which of the following is a sign of postpartum hemorrhage (PPH)?
• A) Bradycardia
• B) Urine retention
• C) Excessive bleeding with a boggy uterus
• D) Decreased respiratory rate
Answer: C) Excessive bleeding with a boggy uterus
Rationale: A boggy uterus (lack of tone) with excessive bleeding is a
common sign of postpartum hemorrhage, which can occur due to
uterine atony or other factors. Bradycardia, urine retention, and
decreased respiratory rate are not common signs of PPH.
2. A nurse is teaching a pregnant woman about the importance of
taking prenatal vitamins. Which of the following vitamins is most
crucial for preventing neural tube defects?
• A) Vitamin A
• B) Vitamin D
• C) Folic acid
• D) Vitamin E
Answer: C) Folic acid
Rationale: Folic acid is essential in the prevention of neural tube
defects, such as spina bifida, in the developing fetus. It is recommended
that women take folic acid before and during early pregnancy.
,3. The nurse is caring for a client in labor. Which of the following
findings indicates the need for immediate intervention?
• A) A ruptured amniotic sac with clear fluid
• B) A prolonged deceleration of fetal heart rate
• C) A cervical dilation of 6 cm
• D) A frequency of contractions every 4-5 minutes
Answer: B) A prolonged deceleration of fetal heart rate
Rationale: A prolonged deceleration of fetal heart rate may indicate
fetal distress and requires immediate intervention, such as changing the
mother's position, administering oxygen, or notifying the healthcare
provider.
4. A nurse is caring for a postpartum client. Which of the following
interventions is the priority for managing uterine atony?
• A) Administering an oxytocin infusion
• B) Providing warm compresses to the abdomen
• C) Massaging the fundus to stimulate uterine contraction
• D) Administering a pain reliever
Answer: C) Massaging the fundus to stimulate uterine contraction
Rationale: Massaging the fundus is the first intervention for uterine
atony to help stimulate contraction and reduce bleeding. If ineffective,
oxytocin or other interventions may be considered.
5. Which of the following is a contraindication for breastfeeding?
, • A) A mild fever
• B) A cracked nipple
• C) Active tuberculosis in the mother
• D) Mastitis
Answer: C) Active tuberculosis in the mother
Rationale: A mother with active tuberculosis should not breastfeed
until she is no longer contagious. Other conditions, such as cracked
nipples or mastitis, do not generally contraindicate breastfeeding with
proper management.
6. A nurse is caring for a client who is at 38 weeks gestation and is
experiencing preeclampsia. Which of the following interventions is the
priority?
• A) Monitor the client's blood pressure every 4 hours
• B) Administer magnesium sulfate to prevent seizures
• C) Assess the fetal heart rate continuously
• D) Encourage the client to rest in a left-sided position
Answer: B) Administer magnesium sulfate to prevent seizures
Rationale: Magnesium sulfate is given to prevent seizures in clients with
severe preeclampsia or eclampsia. Continuous monitoring of the fetal
heart rate and positioning are also important, but seizure prevention
takes priority.
,7. A nurse is providing teaching to a client who is 32 weeks pregnant
about the signs of preterm labor. Which of the following statements
by the client indicates an understanding of the teaching?
• A) "I should seek medical help if I feel pelvic pressure or have
lower back pain."
• B) "I will stop drinking fluids if I feel contractions."
• C) "I can expect my baby to be born around 40 weeks of
pregnancy."
• D) "I should wait until the contractions become very painful before
calling my doctor."
Answer: A) "I should seek medical help if I feel pelvic pressure or have
lower back pain."
Rationale: Pelvic pressure and lower back pain can be signs of preterm
labor. Early intervention is important to prevent premature birth. The
other statements are either incorrect or misleading.
8. The nurse is assessing a newborn and notices that the baby’s skin
has a yellowish tint. The nurse should recognize this as a sign of which
of the following conditions?
• A) Respiratory distress syndrome
• B) Hyperbilirubinemia
• C) Hypoglycemia
• D) Hypothermia
Answer: B) Hyperbilirubinemia
,Rationale: Jaundice in a newborn, indicated by yellowing of the skin
and eyes, is a sign of hyperbilirubinemia. It occurs when the liver cannot
adequately process bilirubin. Immediate assessment and treatment are
necessary to prevent complications.
9. A nurse is preparing to administer an epidural block for a client in
labor. Which of the following assessments should be completed first?
• A) Perform a pelvic examination to determine cervical dilation
• B) Check the client's blood pressure and heart rate
• C) Confirm that the client has signed the consent form
• D) Verify that the client has an empty bladder
Answer: B) Check the client's blood pressure and heart rate
Rationale: The nurse should assess the client's blood pressure and
heart rate prior to administering an epidural block to ensure the client
is stable and to prevent complications like hypotension.
10. A nurse is caring for a postpartum client who has a history of deep
vein thrombosis (DVT). Which of the following interventions should
the nurse implement?
• A) Encourage early ambulation and leg exercises
• B) Administer low-molecular-weight heparin as prescribed
• C) Apply compression stockings to both legs
• D) Massage the client's legs to promote circulation
Answer: A) Encourage early ambulation and leg exercises
,Rationale: Early ambulation and leg exercises are crucial to prevent the
formation of further blood clots and to promote circulation. Massaging
the legs or applying compression stockings without proper consultation
can be harmful, especially in the presence of a clot.
11. A nurse is caring for a client who is 10 hours postpartum and is
experiencing heavy lochia with large clots. The nurse should take
which of the following actions first?
• A) Assess the client’s vital signs
• B) Perform a fundal massage
• C) Administer an oxytocin infusion
• D) Encourage the client to void
Answer: B) Perform a fundal massage
Rationale: The first action to take when a client has heavy lochia with
clots is to perform a fundal massage to assess for uterine atony, which
may be the cause of excessive bleeding. Other interventions, such as
administering oxytocin, can be done after ensuring the uterus is
contracted.
12. A nurse is providing care to a pregnant client at 28 weeks gestation
who is complaining of blurred vision, headache, and swelling of the
face and hands. Which of the following actions should the nurse take
first?
• A) Check the client's blood pressure
• B) Administer a dose of magnesium sulfate
• C) Perform a urine dipstick for protein
, • D) Notify the healthcare provider
Answer: A) Check the client's blood pressure
Rationale: These symptoms could indicate preeclampsia, which is
associated with high blood pressure. The first action is to check the
client's blood pressure to confirm the diagnosis. The nurse can then
take further actions, such as notifying the healthcare provider or
performing other tests.
13. A nurse is teaching a client who is 36 weeks pregnant about signs
of labor. Which of the following statements by the client indicates an
understanding of the teaching?
• A) "I will call my healthcare provider if I notice contractions every
15 minutes."
• B) "I should go to the hospital when my contractions are 5 minutes
apart."
• C) "If I feel my water break, I should wait 24 hours before going to
the hospital."
• D) "I will call my healthcare provider if I have no contractions at
all."
Answer: B) "I should go to the hospital when my contractions are 5
minutes apart."
Rationale: Contractions that are 5 minutes apart, lasting 60 seconds,
are a common indicator that labor has begun and that the client should
go to the hospital. Waiting for 24 hours after the water breaks can lead
to complications, and no contractions are not a sign of labor.
,14. A nurse is assessing a newborn who is 6 hours old. Which of the
following findings is most concerning and should be reported to the
healthcare provider?
• A) A temperature of 98.6°F (37°C)
• B) A respiratory rate of 60 breaths/min
• C) A heart rate of 150 beats/min
• D) A blood glucose level of 35 mg/dL
Answer: D) A blood glucose level of 35 mg/dL
Rationale: A blood glucose level of 35 mg/dL is low and indicates
hypoglycemia, which is a critical condition in newborns. Early
intervention is necessary to prevent complications. The other findings
are normal for a newborn.
15. A nurse is caring for a client who is 24 hours postpartum and is
experiencing difficulty breastfeeding. The nurse observes that the
infant is latching on but is not feeding effectively. Which of the
following actions should the nurse take first?
• A) Assess the infant’s latch
• B) Encourage the mother to use a breast pump
• C) Suggest formula feeding as an alternative
• D) Teach the mother how to bottle-feed the infant
Answer: A) Assess the infant’s latch
Rationale: The first step in addressing breastfeeding difficulties is to
assess the infant's latch. A poor latch can prevent effective feeding, and
,correction of the latch can resolve the issue. Other actions, like formula
feeding or pumping, may be needed if the latch issue persists.
16. A nurse is caring for a client who is 30 weeks pregnant and is
experiencing lower abdominal pain and vaginal bleeding. Which of the
following conditions should the nurse suspect?
• A) Placental abruption
• B) Placenta previa
• C) Preterm labor
• D) Ectopic pregnancy
Answer: A) Placental abruption
Rationale: Placental abruption is characterized by abdominal pain and
vaginal bleeding, and it can occur in the second or third trimester.
Placenta previa typically causes painless bleeding, and preterm labor is
characterized by contractions rather than bleeding.
17. A nurse is caring for a client who is at 38 weeks of pregnancy and
is being induced with oxytocin. The nurse notices that the fetal heart
rate has decelerated. Which of the following interventions should the
nurse implement first?
• A) Increase the rate of the oxytocin infusion
• B) Turn the client to her left side
• C) Administer oxygen to the client
• D) Discontinue the oxytocin infusion
Answer: B) Turn the client to her left side
, Rationale: Turning the client to her left side helps improve blood flow to
the uterus and placenta, which can improve fetal heart rate patterns. If
this does not resolve the deceleration, further interventions, such as
oxygen administration or discontinuing oxytocin, may be necessary.
18. A nurse is teaching a client about newborn care. Which of the
following statements by the client indicates a need for further
teaching regarding cord care?
• A) "I will clean the cord with soap and water."
• B) "I will fold the diaper below the cord stump."
• C) "I will apply alcohol to the cord stump daily."
• D) "I will avoid covering the cord stump with a tight bandage."
Answer: C) "I will apply alcohol to the cord stump daily."
Rationale: Applying alcohol to the umbilical cord stump is no longer
recommended, as it can delay healing. The stump should be kept clean
and dry, and the diaper should be folded below it to prevent irritation.
19. A nurse is caring for a postpartum client who is experiencing
difficulty voiding. Which of the following actions should the nurse take
first?
• A) Encourage the client to drink fluids
• B) Perform a bladder scan
• C) Administer a catheterization
• D) Encourage the client to ambulate
Answer: D) Encourage the client to ambulate
• A) Bradycardia
• B) Urine retention
• C) Excessive bleeding with a boggy uterus
• D) Decreased respiratory rate
Answer: C) Excessive bleeding with a boggy uterus
Rationale: A boggy uterus (lack of tone) with excessive bleeding is a
common sign of postpartum hemorrhage, which can occur due to
uterine atony or other factors. Bradycardia, urine retention, and
decreased respiratory rate are not common signs of PPH.
2. A nurse is teaching a pregnant woman about the importance of
taking prenatal vitamins. Which of the following vitamins is most
crucial for preventing neural tube defects?
• A) Vitamin A
• B) Vitamin D
• C) Folic acid
• D) Vitamin E
Answer: C) Folic acid
Rationale: Folic acid is essential in the prevention of neural tube
defects, such as spina bifida, in the developing fetus. It is recommended
that women take folic acid before and during early pregnancy.
,3. The nurse is caring for a client in labor. Which of the following
findings indicates the need for immediate intervention?
• A) A ruptured amniotic sac with clear fluid
• B) A prolonged deceleration of fetal heart rate
• C) A cervical dilation of 6 cm
• D) A frequency of contractions every 4-5 minutes
Answer: B) A prolonged deceleration of fetal heart rate
Rationale: A prolonged deceleration of fetal heart rate may indicate
fetal distress and requires immediate intervention, such as changing the
mother's position, administering oxygen, or notifying the healthcare
provider.
4. A nurse is caring for a postpartum client. Which of the following
interventions is the priority for managing uterine atony?
• A) Administering an oxytocin infusion
• B) Providing warm compresses to the abdomen
• C) Massaging the fundus to stimulate uterine contraction
• D) Administering a pain reliever
Answer: C) Massaging the fundus to stimulate uterine contraction
Rationale: Massaging the fundus is the first intervention for uterine
atony to help stimulate contraction and reduce bleeding. If ineffective,
oxytocin or other interventions may be considered.
5. Which of the following is a contraindication for breastfeeding?
, • A) A mild fever
• B) A cracked nipple
• C) Active tuberculosis in the mother
• D) Mastitis
Answer: C) Active tuberculosis in the mother
Rationale: A mother with active tuberculosis should not breastfeed
until she is no longer contagious. Other conditions, such as cracked
nipples or mastitis, do not generally contraindicate breastfeeding with
proper management.
6. A nurse is caring for a client who is at 38 weeks gestation and is
experiencing preeclampsia. Which of the following interventions is the
priority?
• A) Monitor the client's blood pressure every 4 hours
• B) Administer magnesium sulfate to prevent seizures
• C) Assess the fetal heart rate continuously
• D) Encourage the client to rest in a left-sided position
Answer: B) Administer magnesium sulfate to prevent seizures
Rationale: Magnesium sulfate is given to prevent seizures in clients with
severe preeclampsia or eclampsia. Continuous monitoring of the fetal
heart rate and positioning are also important, but seizure prevention
takes priority.
,7. A nurse is providing teaching to a client who is 32 weeks pregnant
about the signs of preterm labor. Which of the following statements
by the client indicates an understanding of the teaching?
• A) "I should seek medical help if I feel pelvic pressure or have
lower back pain."
• B) "I will stop drinking fluids if I feel contractions."
• C) "I can expect my baby to be born around 40 weeks of
pregnancy."
• D) "I should wait until the contractions become very painful before
calling my doctor."
Answer: A) "I should seek medical help if I feel pelvic pressure or have
lower back pain."
Rationale: Pelvic pressure and lower back pain can be signs of preterm
labor. Early intervention is important to prevent premature birth. The
other statements are either incorrect or misleading.
8. The nurse is assessing a newborn and notices that the baby’s skin
has a yellowish tint. The nurse should recognize this as a sign of which
of the following conditions?
• A) Respiratory distress syndrome
• B) Hyperbilirubinemia
• C) Hypoglycemia
• D) Hypothermia
Answer: B) Hyperbilirubinemia
,Rationale: Jaundice in a newborn, indicated by yellowing of the skin
and eyes, is a sign of hyperbilirubinemia. It occurs when the liver cannot
adequately process bilirubin. Immediate assessment and treatment are
necessary to prevent complications.
9. A nurse is preparing to administer an epidural block for a client in
labor. Which of the following assessments should be completed first?
• A) Perform a pelvic examination to determine cervical dilation
• B) Check the client's blood pressure and heart rate
• C) Confirm that the client has signed the consent form
• D) Verify that the client has an empty bladder
Answer: B) Check the client's blood pressure and heart rate
Rationale: The nurse should assess the client's blood pressure and
heart rate prior to administering an epidural block to ensure the client
is stable and to prevent complications like hypotension.
10. A nurse is caring for a postpartum client who has a history of deep
vein thrombosis (DVT). Which of the following interventions should
the nurse implement?
• A) Encourage early ambulation and leg exercises
• B) Administer low-molecular-weight heparin as prescribed
• C) Apply compression stockings to both legs
• D) Massage the client's legs to promote circulation
Answer: A) Encourage early ambulation and leg exercises
,Rationale: Early ambulation and leg exercises are crucial to prevent the
formation of further blood clots and to promote circulation. Massaging
the legs or applying compression stockings without proper consultation
can be harmful, especially in the presence of a clot.
11. A nurse is caring for a client who is 10 hours postpartum and is
experiencing heavy lochia with large clots. The nurse should take
which of the following actions first?
• A) Assess the client’s vital signs
• B) Perform a fundal massage
• C) Administer an oxytocin infusion
• D) Encourage the client to void
Answer: B) Perform a fundal massage
Rationale: The first action to take when a client has heavy lochia with
clots is to perform a fundal massage to assess for uterine atony, which
may be the cause of excessive bleeding. Other interventions, such as
administering oxytocin, can be done after ensuring the uterus is
contracted.
12. A nurse is providing care to a pregnant client at 28 weeks gestation
who is complaining of blurred vision, headache, and swelling of the
face and hands. Which of the following actions should the nurse take
first?
• A) Check the client's blood pressure
• B) Administer a dose of magnesium sulfate
• C) Perform a urine dipstick for protein
, • D) Notify the healthcare provider
Answer: A) Check the client's blood pressure
Rationale: These symptoms could indicate preeclampsia, which is
associated with high blood pressure. The first action is to check the
client's blood pressure to confirm the diagnosis. The nurse can then
take further actions, such as notifying the healthcare provider or
performing other tests.
13. A nurse is teaching a client who is 36 weeks pregnant about signs
of labor. Which of the following statements by the client indicates an
understanding of the teaching?
• A) "I will call my healthcare provider if I notice contractions every
15 minutes."
• B) "I should go to the hospital when my contractions are 5 minutes
apart."
• C) "If I feel my water break, I should wait 24 hours before going to
the hospital."
• D) "I will call my healthcare provider if I have no contractions at
all."
Answer: B) "I should go to the hospital when my contractions are 5
minutes apart."
Rationale: Contractions that are 5 minutes apart, lasting 60 seconds,
are a common indicator that labor has begun and that the client should
go to the hospital. Waiting for 24 hours after the water breaks can lead
to complications, and no contractions are not a sign of labor.
,14. A nurse is assessing a newborn who is 6 hours old. Which of the
following findings is most concerning and should be reported to the
healthcare provider?
• A) A temperature of 98.6°F (37°C)
• B) A respiratory rate of 60 breaths/min
• C) A heart rate of 150 beats/min
• D) A blood glucose level of 35 mg/dL
Answer: D) A blood glucose level of 35 mg/dL
Rationale: A blood glucose level of 35 mg/dL is low and indicates
hypoglycemia, which is a critical condition in newborns. Early
intervention is necessary to prevent complications. The other findings
are normal for a newborn.
15. A nurse is caring for a client who is 24 hours postpartum and is
experiencing difficulty breastfeeding. The nurse observes that the
infant is latching on but is not feeding effectively. Which of the
following actions should the nurse take first?
• A) Assess the infant’s latch
• B) Encourage the mother to use a breast pump
• C) Suggest formula feeding as an alternative
• D) Teach the mother how to bottle-feed the infant
Answer: A) Assess the infant’s latch
Rationale: The first step in addressing breastfeeding difficulties is to
assess the infant's latch. A poor latch can prevent effective feeding, and
,correction of the latch can resolve the issue. Other actions, like formula
feeding or pumping, may be needed if the latch issue persists.
16. A nurse is caring for a client who is 30 weeks pregnant and is
experiencing lower abdominal pain and vaginal bleeding. Which of the
following conditions should the nurse suspect?
• A) Placental abruption
• B) Placenta previa
• C) Preterm labor
• D) Ectopic pregnancy
Answer: A) Placental abruption
Rationale: Placental abruption is characterized by abdominal pain and
vaginal bleeding, and it can occur in the second or third trimester.
Placenta previa typically causes painless bleeding, and preterm labor is
characterized by contractions rather than bleeding.
17. A nurse is caring for a client who is at 38 weeks of pregnancy and
is being induced with oxytocin. The nurse notices that the fetal heart
rate has decelerated. Which of the following interventions should the
nurse implement first?
• A) Increase the rate of the oxytocin infusion
• B) Turn the client to her left side
• C) Administer oxygen to the client
• D) Discontinue the oxytocin infusion
Answer: B) Turn the client to her left side
, Rationale: Turning the client to her left side helps improve blood flow to
the uterus and placenta, which can improve fetal heart rate patterns. If
this does not resolve the deceleration, further interventions, such as
oxygen administration or discontinuing oxytocin, may be necessary.
18. A nurse is teaching a client about newborn care. Which of the
following statements by the client indicates a need for further
teaching regarding cord care?
• A) "I will clean the cord with soap and water."
• B) "I will fold the diaper below the cord stump."
• C) "I will apply alcohol to the cord stump daily."
• D) "I will avoid covering the cord stump with a tight bandage."
Answer: C) "I will apply alcohol to the cord stump daily."
Rationale: Applying alcohol to the umbilical cord stump is no longer
recommended, as it can delay healing. The stump should be kept clean
and dry, and the diaper should be folded below it to prevent irritation.
19. A nurse is caring for a postpartum client who is experiencing
difficulty voiding. Which of the following actions should the nurse take
first?
• A) Encourage the client to drink fluids
• B) Perform a bladder scan
• C) Administer a catheterization
• D) Encourage the client to ambulate
Answer: D) Encourage the client to ambulate
