Maternal-Newborn Nursing Practice Exam 9 Questions |Answers
|Rationales
1. A nurse is monitoring a client who is receiving magnesium sulfate for
preeclampsia. Which finding should the nurse report to the provider
immediately?
A. Urinary output of 40 mL/hr
B. Deep tendon reflexes of 2+
C. Blood pressure of 148/94 mmHg
D. Respiratory rate of 10/min
Answer: D
Rationale: A respiratory rate of less than 12/min is a sign of magnesium toxicity and
requires immediate intervention, including stopping the infusion and notifying the
provider.
2. A nurse is caring for a client in the first stage of labor. The fetal heart rate
(FHR) monitor shows late decelerations. Which of the following actions should
the nurse take first?
A. Administer oxygen via face mask at 8 to 10 L/min
B. Turn the client to a side-lying position
C. Increase the rate of the IV fluid infusion
D. Perform a vaginal examination
Answer: B
Rationale: The first action for late decelerations is to improve placental perfusion by
turning the client to a side-lying position to relieve pressure on the inferior vena cava.
,3. Which of the following findings is characteristic of a client experiencing
abruptio placentae?
A. Painless, bright red vaginal bleeding
B. Soft, relaxed, non-tender uterus
C. Board-like, rigid, tender abdomen
D. Fetal heart rate within normal limits
Answer: C
Rationale: Abruptio placentae is characterized by sudden onset of intense localized
abdominal pain and a rigid, board-like uterus, often accompanied by dark red vaginal
bleeding.
4. A nurse is assessing a newborn 1 hour after birth. Which of the following
findings should be reported to the provider?
A. Acrocyanosis of the hands and feet
B. Generalized petechiae over the body
C. Heart rate of 140/min
D. Milia on the nose
Answer: B
Rationale: Generalized petechiae can indicate a clotting factor deficiency or infection and
should be reported. Acrocyanosis and milia are normal newborn findings.
5. A client at 32 weeks gestation is diagnosed with gestational diabetes. Which
of the following instructions should the nurse include in the teaching?
A. Perform daily fetal kick counts
B. Exercise should be limited to avoid hypoglycemia
C. You should avoid all carbohydrates in your diet
D. Check your blood glucose levels once weekly
Answer: A
, Rationale: Clients with gestational diabetes are at higher risk for stillbirth; daily fetal kick
counts are recommended to monitor fetal well-being.
6. A nurse is providing discharge teaching to a postpartum client. Which of the
following should the nurse include as a sign of postpartum infection?
A. Lochia rubra on day 2 postpartum
B. Engorged breasts that are firm and warm
C. Bradycardia of 50/min
D. Fever of 38°C (100.4°F) or higher after the first 24 hours
Answer: D
Rationale: A temperature of 38°C (100.4°F) or higher on two separate occasions after the
first 24 hours postpartum is a classic indicator of infection.
7. A nurse is preparing to administer Vitamin K (phytonadione) to a newborn.
What is the primary purpose of this medication?
A. To prevent neonatal jaundice
B. To prevent hemorrhagic disease of the newborn
C. To provide immunity against Hepatitis B
D. To stimulate surfactant production
Answer: B
Rationale: Newborns have low levels of Vitamin K due to a sterile gut. Vitamin K is
essential for the synthesis of clotting factors and prevents bleeding.
8. What is the significance of a positive Coombs’ test in a postpartum Rh-
negative client?
A. The newborn is Rh-negative
B. The client requires Rho(D) immune globulin within 72 hours
C. The client has developed antibodies against Rh-positive blood
D. The client is immune to Rubella
Answer: C
|Rationales
1. A nurse is monitoring a client who is receiving magnesium sulfate for
preeclampsia. Which finding should the nurse report to the provider
immediately?
A. Urinary output of 40 mL/hr
B. Deep tendon reflexes of 2+
C. Blood pressure of 148/94 mmHg
D. Respiratory rate of 10/min
Answer: D
Rationale: A respiratory rate of less than 12/min is a sign of magnesium toxicity and
requires immediate intervention, including stopping the infusion and notifying the
provider.
2. A nurse is caring for a client in the first stage of labor. The fetal heart rate
(FHR) monitor shows late decelerations. Which of the following actions should
the nurse take first?
A. Administer oxygen via face mask at 8 to 10 L/min
B. Turn the client to a side-lying position
C. Increase the rate of the IV fluid infusion
D. Perform a vaginal examination
Answer: B
Rationale: The first action for late decelerations is to improve placental perfusion by
turning the client to a side-lying position to relieve pressure on the inferior vena cava.
,3. Which of the following findings is characteristic of a client experiencing
abruptio placentae?
A. Painless, bright red vaginal bleeding
B. Soft, relaxed, non-tender uterus
C. Board-like, rigid, tender abdomen
D. Fetal heart rate within normal limits
Answer: C
Rationale: Abruptio placentae is characterized by sudden onset of intense localized
abdominal pain and a rigid, board-like uterus, often accompanied by dark red vaginal
bleeding.
4. A nurse is assessing a newborn 1 hour after birth. Which of the following
findings should be reported to the provider?
A. Acrocyanosis of the hands and feet
B. Generalized petechiae over the body
C. Heart rate of 140/min
D. Milia on the nose
Answer: B
Rationale: Generalized petechiae can indicate a clotting factor deficiency or infection and
should be reported. Acrocyanosis and milia are normal newborn findings.
5. A client at 32 weeks gestation is diagnosed with gestational diabetes. Which
of the following instructions should the nurse include in the teaching?
A. Perform daily fetal kick counts
B. Exercise should be limited to avoid hypoglycemia
C. You should avoid all carbohydrates in your diet
D. Check your blood glucose levels once weekly
Answer: A
, Rationale: Clients with gestational diabetes are at higher risk for stillbirth; daily fetal kick
counts are recommended to monitor fetal well-being.
6. A nurse is providing discharge teaching to a postpartum client. Which of the
following should the nurse include as a sign of postpartum infection?
A. Lochia rubra on day 2 postpartum
B. Engorged breasts that are firm and warm
C. Bradycardia of 50/min
D. Fever of 38°C (100.4°F) or higher after the first 24 hours
Answer: D
Rationale: A temperature of 38°C (100.4°F) or higher on two separate occasions after the
first 24 hours postpartum is a classic indicator of infection.
7. A nurse is preparing to administer Vitamin K (phytonadione) to a newborn.
What is the primary purpose of this medication?
A. To prevent neonatal jaundice
B. To prevent hemorrhagic disease of the newborn
C. To provide immunity against Hepatitis B
D. To stimulate surfactant production
Answer: B
Rationale: Newborns have low levels of Vitamin K due to a sterile gut. Vitamin K is
essential for the synthesis of clotting factors and prevents bleeding.
8. What is the significance of a positive Coombs’ test in a postpartum Rh-
negative client?
A. The newborn is Rh-negative
B. The client requires Rho(D) immune globulin within 72 hours
C. The client has developed antibodies against Rh-positive blood
D. The client is immune to Rubella
Answer: C
