ACTUAL EXAM QUESTIONS AND CORRECT
ANSWERS WITH RATIONALES GRADED A+ LATEST
1. A 28-week gestation client reports vaginal bleeding and mild cramping.
Which action should the nurse take first?
A. Assess vital signs and fetal heart rate
B. Encourage ambulation
C. Provide education about nutrition
D. Document findings only
Correct Answer: A
Rationale:
Vaginal bleeding and cramping in the second trimester could indicate preterm
labor or placental complications. Assessing maternal hemodynamics and fetal
status is priority.
2. A client at 39 weeks gestation is admitted with spontaneous rupture of
membranes. Which action should the nurse take first?
A. Assess fetal heart rate
B. Encourage ambulation
C. Prepare for immediate C-section
D. Administer oxytocin immediately
Correct Answer: A
Rationale:
Rupture of membranes can lead to cord prolapse or infection → immediate
assessment of fetal heart rate is critical.
,3. A postpartum client reports large clots and soaking one pad per hour. What
is the priority action?
A. Assess fundal tone and vital signs
B. Encourage ambulation
C. Document and monitor
D. Offer oral fluids
Correct Answer: A
Rationale:
Heavy bleeding may indicate postpartum hemorrhage → assessment guides
immediate interventions like uterine massage or medications.
4. A neonate is born at 32 weeks gestation. Which assessment finding requires
immediate action?
A. Respiratory rate 70/min with grunting and nasal flaring
B. Crying vigorously
C. Pink skin color
D. Strong reflexes
Correct Answer: A
Rationale:
Premature infants are at risk for respiratory distress syndrome → grunting and
nasal flaring indicate hypoxia requiring intervention.
5. A laboring client has a fetal heart rate of 180 bpm with moderate
variability. Which intervention is appropriate?
A. Assess maternal temperature and signs of infection
B. Continue routine monitoring only
C. Administer oxytocin
D. Encourage ambulation
Correct Answer: A
,Rationale:
Tachycardia with moderate variability may indicate maternal infection
(chorioamnionitis) → assessment and intervention are required.
6. A postpartum client has a temperature of 38.3°C on day 2. What is the
priority action?
A. Assess for uterine tenderness, lochia, and signs of infection
B. Encourage ambulation
C. Administer acetaminophen only
D. Document and monitor
Correct Answer: A
Rationale:
Fever in the postpartum period may indicate infection (endometritis or wound
infection) → assessment guides treatment.
7. A client with preeclampsia at 36 weeks has BP 160/110 mmHg and
headache. Which action is priority?
A. Administer antihypertensive per protocol
B. Encourage ambulation
C. Provide dietary teaching
D. Document and monitor
Correct Answer: A
Rationale:
Severe preeclampsia can cause maternal stroke, seizures → rapid BP
management is critical.
, 8. A client at 32 weeks gestation is diagnosed with gestational diabetes. Which
instruction is priority?
A. Monitor blood glucose and follow dietary plan
B. Encourage ambulation only
C. Restrict fluids
D. Begin iron supplementation
Correct Answer: A
Rationale:
Maternal hyperglycemia increases risk for fetal macrosomia and complications
→ monitoring and diet are critical.
9. A client at 38 weeks gestation has painless, bright red vaginal bleeding.
What is the priority action?
A. Assess fetal heart rate and maternal vital signs
B. Encourage ambulation
C. Provide reassurance
D. Offer fluids only
Correct Answer: A
Rationale:
Bright red painless bleeding may indicate placenta previa → assessment guides
safe delivery planning.
10. A postpartum client has a boggy uterus and saturated pads. Which
intervention is first?
A. Massage the fundus
B. Encourage fluids
C. Monitor vitals only
D. Document findings
Correct Answer: A