Maternal-Newborn Nursing Practice Exam 7 Questions |Answers
|Rationales
1. A nurse is calculating the estimated date of birth using Naegele’s rule for a
client whose last menstrual period began on May 4th. Which date should the
nurse provide?
A. January 11th
B. February 11th
C. February 4th
D. January 4th
Answer: B
Rationale: Naegele’s rule involves subtracting 3 months and adding 7 days and 1 year to
the first day of the last menstrual period (May 4 - 3 months = February 4, + 7 days =
February 11).
2. A nurse is assessing a pregnant client in her second trimester. Which of the
following findings should the nurse report to the provider as a presumptive sign
of pregnancy?
A. Goodell’s sign
B. Positive pregnancy test
C. Fetal heart tones heard by Doppler
D. Amenorrhea
Answer: D
Rationale: Presumptive signs are subjective changes experienced by the woman, such as
amenorrhea, fatigue, and nausea. Positive pregnancy tests and Goodell’s sign are probable
signs, while fetal heart tones are positive signs.
,3. A client at 32 weeks of gestation is receiving magnesium sulfate IV for
preeclampsia. Which finding is the priority for the nurse to report?
A. Deep tendon reflexes of 2+
B. Urine output of 20 mL/hr
C. Respiratory rate of 14/min
D. Serum magnesium level of 6 mg/dL
Answer: B
Rationale: Urine output less than 30 mL/hr indicates a risk for magnesium toxicity
because the drug is excreted via the kidneys. DTRs of 2+ and RR of 14 are normal findings;
therapeutic magnesium levels are 4-7 mg/dL.
4. A nurse is caring for a client who is in the first stage of labor and notes late
decelerations on the fetal monitor. What is the priority nursing action?
A. Administer oxygen via nonrebreather mask at 8-10 L/min
B. Assist the client into a supine position
C. Increase the oxytocin infusion rate
D. Prepare for an immediate forceps delivery
Answer: A
Rationale: Late decelerations indicate uteroplacental insufficiency. Priority interventions
include turning the client to the side, discontinuing oxytocin, increasing IV fluids, and
administering oxygen.
5. Which of the following is a normal finding in a newborn within the first 24
hours of life?
A. Jaundice of the face and sclera
B. Expiratory grunting and nasal flaring
C. Blood glucose of 30 mg/dL
D. Acrocyanosis of the hands and feet
Answer: D
, Rationale: Acrocyanosis is a normal finding in the first 24-48 hours due to poor peripheral
circulation. Jaundice in the first 24 hours is pathological; grunting and flaring indicate
distress; glucose should be above 40 mg/dL.
6. A nurse is teaching a postpartum client about rubella vaccination. Which
statement by the client indicates understanding?
A. I should avoid becoming pregnant for at least 1 month.
B. I will need a booster in 2 weeks.
C. I should stop breastfeeding for 24 hours after the shot.
D. This vaccine will prevent my baby from getting rubella via breast milk.
Answer: A
Rationale: The rubella vaccine is a live virus and is teratogenic. Clients are advised to avoid
pregnancy for 28 days to 1 month to prevent fetal rubella syndrome.
7. A client is 4 hours postpartum and has a boggy uterus that is displaced to the
right. What is the first action the nurse should take?
A. Administer oxytocin IM
B. Massage the fundus until firm
C. Assist the client to the bathroom to void
D. Perform a straight catheterization
Answer: C
Rationale: A uterus displaced to the right is usually caused by a full bladder. Assisting the
client to void allows the uterus to return to the midline and contract effectively. Massage is
done if it remains boggy after voiding.
|Rationales
1. A nurse is calculating the estimated date of birth using Naegele’s rule for a
client whose last menstrual period began on May 4th. Which date should the
nurse provide?
A. January 11th
B. February 11th
C. February 4th
D. January 4th
Answer: B
Rationale: Naegele’s rule involves subtracting 3 months and adding 7 days and 1 year to
the first day of the last menstrual period (May 4 - 3 months = February 4, + 7 days =
February 11).
2. A nurse is assessing a pregnant client in her second trimester. Which of the
following findings should the nurse report to the provider as a presumptive sign
of pregnancy?
A. Goodell’s sign
B. Positive pregnancy test
C. Fetal heart tones heard by Doppler
D. Amenorrhea
Answer: D
Rationale: Presumptive signs are subjective changes experienced by the woman, such as
amenorrhea, fatigue, and nausea. Positive pregnancy tests and Goodell’s sign are probable
signs, while fetal heart tones are positive signs.
,3. A client at 32 weeks of gestation is receiving magnesium sulfate IV for
preeclampsia. Which finding is the priority for the nurse to report?
A. Deep tendon reflexes of 2+
B. Urine output of 20 mL/hr
C. Respiratory rate of 14/min
D. Serum magnesium level of 6 mg/dL
Answer: B
Rationale: Urine output less than 30 mL/hr indicates a risk for magnesium toxicity
because the drug is excreted via the kidneys. DTRs of 2+ and RR of 14 are normal findings;
therapeutic magnesium levels are 4-7 mg/dL.
4. A nurse is caring for a client who is in the first stage of labor and notes late
decelerations on the fetal monitor. What is the priority nursing action?
A. Administer oxygen via nonrebreather mask at 8-10 L/min
B. Assist the client into a supine position
C. Increase the oxytocin infusion rate
D. Prepare for an immediate forceps delivery
Answer: A
Rationale: Late decelerations indicate uteroplacental insufficiency. Priority interventions
include turning the client to the side, discontinuing oxytocin, increasing IV fluids, and
administering oxygen.
5. Which of the following is a normal finding in a newborn within the first 24
hours of life?
A. Jaundice of the face and sclera
B. Expiratory grunting and nasal flaring
C. Blood glucose of 30 mg/dL
D. Acrocyanosis of the hands and feet
Answer: D
, Rationale: Acrocyanosis is a normal finding in the first 24-48 hours due to poor peripheral
circulation. Jaundice in the first 24 hours is pathological; grunting and flaring indicate
distress; glucose should be above 40 mg/dL.
6. A nurse is teaching a postpartum client about rubella vaccination. Which
statement by the client indicates understanding?
A. I should avoid becoming pregnant for at least 1 month.
B. I will need a booster in 2 weeks.
C. I should stop breastfeeding for 24 hours after the shot.
D. This vaccine will prevent my baby from getting rubella via breast milk.
Answer: A
Rationale: The rubella vaccine is a live virus and is teratogenic. Clients are advised to avoid
pregnancy for 28 days to 1 month to prevent fetal rubella syndrome.
7. A client is 4 hours postpartum and has a boggy uterus that is displaced to the
right. What is the first action the nurse should take?
A. Administer oxytocin IM
B. Massage the fundus until firm
C. Assist the client to the bathroom to void
D. Perform a straight catheterization
Answer: C
Rationale: A uterus displaced to the right is usually caused by a full bladder. Assisting the
client to void allows the uterus to return to the midline and contract effectively. Massage is
done if it remains boggy after voiding.
