Maternal-Newborn Nursing Exam 4 Practice 2026 |Questions
|Answers |Rationales
1. A nurse is assessing a postpartum client 4 hours after a vaginal delivery. The
fundus is firm, midline, and at the level of the umbilicus. Which of the following
is the priority nursing action?
A. Massage the fundus vigorously
B. Notify the provider immediately
C. Assist the client to the bathroom
D. Document the findings as normal
Answer: D
Rationale: A firm, midline fundus at the level of the umbilicus is a normal finding 4 hours
postpartum, indicating appropriate uterine involution.
2. Which of the following findings should the nurse expect in a newborn 1 hour
after birth?
A. Heart rate of 80 beats/min
B. Generalized cyanosis
C. Acrocyanosis
D. Respirations of 70 breaths/min
Answer: C
Rationale: Acrocyanosis (bluish discoloration of hands and feet) is a common and normal
finding in the first 24 to 48 hours of life due to poor peripheral circulation.
,3. A client at 32 weeks gestation is receiving magnesium sulfate for
preeclampsia. Which finding is the most concerning?
A. Sleepiness
B. Blood pressure of 140/90 mmHg
C. Absent deep tendon reflexes
D. Urinary output of 40 mL/hr
Answer: C
Rationale: Loss of deep tendon reflexes is an early sign of magnesium sulfate toxicity,
which can lead to respiratory depression and cardiac arrest.
4. What is the primary purpose of administering Vitamin K to a newborn?
A. To prevent ophthalmia neonatorum
B. To promote lung maturity
C. To prevent hemorrhagic disease
D. To stimulate red blood cell production
Answer: C
Rationale: Newborns are born with low levels of Vitamin K because it does not cross the
placenta well and the sterile gut cannot yet synthesize it; Vitamin K is necessary for the
synthesis of clotting factors.
5. A nurse is caring for a client in the first stage of labor. The fetal monitor
shows a pattern of variable decelerations. What is the most likely cause?
A. Uteroplacental insufficiency
B. Fetal head compression
C. Maternal hypotension
D. Umbilical cord compression
Answer: D
, Rationale: Variable decelerations are caused by umbilical cord compression. Early
decelerations relate to head compression, and late decelerations relate to uteroplacental
insufficiency.
6. Which medication is the antidote for magnesium sulfate toxicity?
A. Calcium gluconate
B. Naloxone
C. Terbutaline
D. Oxytocin
Answer: A
Rationale: Calcium gluconate is the specific antagonist used to reverse the effects of
magnesium sulfate toxicity.
7. A client is 2 days postpartum and reports breast engorgement. She is bottle-
feeding her infant. Which instruction should the nurse provide?
A. Wear a tight-fitting supportive bra
B. Express small amounts of milk by hand
C. Apply warm compresses to the breasts
D. Pump the breasts every 4 hours
Answer: A
Rationale: For non-breastfeeding mothers, breast stimulation and heat should be avoided.
A tight-fitting bra and ice packs help suppress lactation and reduce pain.
8. Which of the following is a sign of placenta previa?
A. Rigid, board-like abdomen
B. Painless, bright red vaginal bleeding
C. Severe abdominal pain
D. Persistent dark red bleeding
Answer: B
|Answers |Rationales
1. A nurse is assessing a postpartum client 4 hours after a vaginal delivery. The
fundus is firm, midline, and at the level of the umbilicus. Which of the following
is the priority nursing action?
A. Massage the fundus vigorously
B. Notify the provider immediately
C. Assist the client to the bathroom
D. Document the findings as normal
Answer: D
Rationale: A firm, midline fundus at the level of the umbilicus is a normal finding 4 hours
postpartum, indicating appropriate uterine involution.
2. Which of the following findings should the nurse expect in a newborn 1 hour
after birth?
A. Heart rate of 80 beats/min
B. Generalized cyanosis
C. Acrocyanosis
D. Respirations of 70 breaths/min
Answer: C
Rationale: Acrocyanosis (bluish discoloration of hands and feet) is a common and normal
finding in the first 24 to 48 hours of life due to poor peripheral circulation.
,3. A client at 32 weeks gestation is receiving magnesium sulfate for
preeclampsia. Which finding is the most concerning?
A. Sleepiness
B. Blood pressure of 140/90 mmHg
C. Absent deep tendon reflexes
D. Urinary output of 40 mL/hr
Answer: C
Rationale: Loss of deep tendon reflexes is an early sign of magnesium sulfate toxicity,
which can lead to respiratory depression and cardiac arrest.
4. What is the primary purpose of administering Vitamin K to a newborn?
A. To prevent ophthalmia neonatorum
B. To promote lung maturity
C. To prevent hemorrhagic disease
D. To stimulate red blood cell production
Answer: C
Rationale: Newborns are born with low levels of Vitamin K because it does not cross the
placenta well and the sterile gut cannot yet synthesize it; Vitamin K is necessary for the
synthesis of clotting factors.
5. A nurse is caring for a client in the first stage of labor. The fetal monitor
shows a pattern of variable decelerations. What is the most likely cause?
A. Uteroplacental insufficiency
B. Fetal head compression
C. Maternal hypotension
D. Umbilical cord compression
Answer: D
, Rationale: Variable decelerations are caused by umbilical cord compression. Early
decelerations relate to head compression, and late decelerations relate to uteroplacental
insufficiency.
6. Which medication is the antidote for magnesium sulfate toxicity?
A. Calcium gluconate
B. Naloxone
C. Terbutaline
D. Oxytocin
Answer: A
Rationale: Calcium gluconate is the specific antagonist used to reverse the effects of
magnesium sulfate toxicity.
7. A client is 2 days postpartum and reports breast engorgement. She is bottle-
feeding her infant. Which instruction should the nurse provide?
A. Wear a tight-fitting supportive bra
B. Express small amounts of milk by hand
C. Apply warm compresses to the breasts
D. Pump the breasts every 4 hours
Answer: A
Rationale: For non-breastfeeding mothers, breast stimulation and heat should be avoided.
A tight-fitting bra and ice packs help suppress lactation and reduce pain.
8. Which of the following is a sign of placenta previa?
A. Rigid, board-like abdomen
B. Painless, bright red vaginal bleeding
C. Severe abdominal pain
D. Persistent dark red bleeding
Answer: B
