Maternal-Newborn Nursing Exam 8 Practice Questions 2026 |Answers
|Rationales
1. A nurse is assessing a postpartum client 2 hours after delivery. The fundus is
boggy and displaced to the right. What is the priority nursing action?
A. Encourage the client to void
B. Administer oxytocin
C. Perform fundal massage
D. Notify the healthcare provider
Answer: A
Rationale: A displaced fundus to the right is a classic sign of bladder distention, which
prevents the uterus from contracting effectively. Encouraging the client to void should be
done first to allow the uterus to return to the midline and contract.
2. A newborn at 1 minute of age has a heart rate of 110 bpm, a weak cry, some
flexion of extremities, is grimacing, and has a pink body with blue extremities.
What is the APGAR score?
A. 5
B. 7
C. 6
D. 8
Answer: C
Rationale: HR > 100 (2), weak cry (1), some flexion (1), grimace (1), and acrocyanosis (1)
equals a total score of 6.
,3. During a non-stress test (NST), the nurse observes late decelerations on the
fetal monitor. What does this finding indicate?
A. Fetal head compression
B. Umbilical cord compression
C. Normal fetal movement
D. Uteroplacental insufficiency
Answer: D
Rationale: Late decelerations are caused by uteroplacental insufficiency and are a non-
reassuring sign that requires immediate intervention.
4. A client with preeclampsia is receiving magnesium sulfate. Which assessment
finding should the nurse report as a sign of toxicity?
A. Blood pressure 150/90 mmHg
B. Respiratory rate of 14/min
C. Deep tendon reflexes of 0
D. Urinary output of 40 mL/hr
Answer: C
Rationale: Loss of deep tendon reflexes (0 or 1+) is an early sign of magnesium sulfate
toxicity. Normal reflexes are 2+.
5. A nurse is providing discharge teaching to a client who is Rh-negative and has
an Rh-positive newborn. Which statement should the nurse include?
A. You do not need Rho(D) immune globulin because this was your first baby.
B. The baby will need Rho(D) immune globulin.
C. You will need Rho(D) immune globulin within 72 hours of delivery.
D. Rho(D) immune globulin is only needed during pregnancy, not after.
Answer: C
Rationale: Rh-negative mothers with Rh-positive infants must receive Rho(D) immune
globulin within 72 hours of birth to prevent sensitization for future pregnancies.
, 6. Which of the following is an appropriate nursing intervention for a newborn
receiving phototherapy for jaundice?
A. Apply lotion to the skin to prevent drying.
B. Keep the newborn dressed in a diaper and t-shirt.
C. Cover the newborn’s eyes with opaque masks.
D. Limit fluid intake to prevent diarrhea.
Answer: C
Rationale: Opaque masks are essential to protect the newborn’s retinas from the high-
intensity lights used in phototherapy.
7. A nurse is caring for a client in the transition phase of labor. Which of the
following behavior is typical for this stage?
A. Excitement and talkativeness
B. Calmness and focused breathing
C. Irritability and loss of control
D. Steady urge to push
Answer: C
Rationale: The transition phase (8-10 cm) is often characterized by irritability,
restlessness, and a feeling of being overwhelmed or losing control.
8. A nurse is teaching a parent about umbilical cord care. Which instruction is
correct?
A. Clean the cord with hydrogen peroxide at every diaper change.
B. Keep the diaper folded down below the cord stump.
C. The cord should fall off within 48 hours.
D. Apply antibiotic ointment to the stump daily.
Answer: B
Rationale: Keeping the diaper folded below the stump allows it to air dry and prevents
contamination from urine or stool.
|Rationales
1. A nurse is assessing a postpartum client 2 hours after delivery. The fundus is
boggy and displaced to the right. What is the priority nursing action?
A. Encourage the client to void
B. Administer oxytocin
C. Perform fundal massage
D. Notify the healthcare provider
Answer: A
Rationale: A displaced fundus to the right is a classic sign of bladder distention, which
prevents the uterus from contracting effectively. Encouraging the client to void should be
done first to allow the uterus to return to the midline and contract.
2. A newborn at 1 minute of age has a heart rate of 110 bpm, a weak cry, some
flexion of extremities, is grimacing, and has a pink body with blue extremities.
What is the APGAR score?
A. 5
B. 7
C. 6
D. 8
Answer: C
Rationale: HR > 100 (2), weak cry (1), some flexion (1), grimace (1), and acrocyanosis (1)
equals a total score of 6.
,3. During a non-stress test (NST), the nurse observes late decelerations on the
fetal monitor. What does this finding indicate?
A. Fetal head compression
B. Umbilical cord compression
C. Normal fetal movement
D. Uteroplacental insufficiency
Answer: D
Rationale: Late decelerations are caused by uteroplacental insufficiency and are a non-
reassuring sign that requires immediate intervention.
4. A client with preeclampsia is receiving magnesium sulfate. Which assessment
finding should the nurse report as a sign of toxicity?
A. Blood pressure 150/90 mmHg
B. Respiratory rate of 14/min
C. Deep tendon reflexes of 0
D. Urinary output of 40 mL/hr
Answer: C
Rationale: Loss of deep tendon reflexes (0 or 1+) is an early sign of magnesium sulfate
toxicity. Normal reflexes are 2+.
5. A nurse is providing discharge teaching to a client who is Rh-negative and has
an Rh-positive newborn. Which statement should the nurse include?
A. You do not need Rho(D) immune globulin because this was your first baby.
B. The baby will need Rho(D) immune globulin.
C. You will need Rho(D) immune globulin within 72 hours of delivery.
D. Rho(D) immune globulin is only needed during pregnancy, not after.
Answer: C
Rationale: Rh-negative mothers with Rh-positive infants must receive Rho(D) immune
globulin within 72 hours of birth to prevent sensitization for future pregnancies.
, 6. Which of the following is an appropriate nursing intervention for a newborn
receiving phototherapy for jaundice?
A. Apply lotion to the skin to prevent drying.
B. Keep the newborn dressed in a diaper and t-shirt.
C. Cover the newborn’s eyes with opaque masks.
D. Limit fluid intake to prevent diarrhea.
Answer: C
Rationale: Opaque masks are essential to protect the newborn’s retinas from the high-
intensity lights used in phototherapy.
7. A nurse is caring for a client in the transition phase of labor. Which of the
following behavior is typical for this stage?
A. Excitement and talkativeness
B. Calmness and focused breathing
C. Irritability and loss of control
D. Steady urge to push
Answer: C
Rationale: The transition phase (8-10 cm) is often characterized by irritability,
restlessness, and a feeling of being overwhelmed or losing control.
8. A nurse is teaching a parent about umbilical cord care. Which instruction is
correct?
A. Clean the cord with hydrogen peroxide at every diaper change.
B. Keep the diaper folded down below the cord stump.
C. The cord should fall off within 48 hours.
D. Apply antibiotic ointment to the stump daily.
Answer: B
Rationale: Keeping the diaper folded below the stump allows it to air dry and prevents
contamination from urine or stool.
