Questions and Answers | Latest
Version | 2025/2026 | Correct & Verified
A nurse is caring for a client who is 39 weeks pregnant and reports sudden gush of fluid from the
vagina. What is the nurse’s priority action?
A. Check for meconium in the fluid
✔✔B. Assess fetal heart rate
C. Monitor uterine contractions
D. Document the amount of fluid
A nurse is teaching a new mother how to prevent newborn heat loss by conduction. Which
statement by the mother indicates understanding?
✔✔A. “I will place a warm blanket on the scale before weighing my baby.”
B. “I will keep the baby away from open windows.”
C. “I will dry the baby immediately after birth.”
D. “I will place a hat on the baby’s head.”
A client who is 36 weeks gestation has painless vaginal bleeding. Which condition should the
nurse suspect?
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,A. Abruptio placentae
✔✔B. Placenta previa
C. Ectopic pregnancy
D. Uterine rupture
A nurse is reviewing lab results of a newborn who is 12 hours old. Which of the following
findings requires immediate intervention?
A. Hematocrit 52%
✔✔B. Blood glucose 28 mg/dL
C. Respiratory rate 58/min
D. Bilirubin 4 mg/dL
A nurse is caring for a client in labor and observes variable decelerations on the fetal heart rate
tracing. What is the nurse’s priority action?
A. Give oxygen via face mask
✔✔B. Reposition the client
C. Increase IV fluids
D. Call the provider
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,A nurse is caring for a postpartum client who has saturated a perineal pad in 15 minutes. What is
the nurse’s first action?
A. Check the client’s blood pressure
B. Massage the fundus
✔✔C. Assess fundal firmness
D. Call the provider immediately
A nurse is assessing a newborn 30 minutes after delivery. Which of the following findings
requires immediate attention?
✔✔A. Grunting with nasal flaring
B. Acrocyanosis
C. Heart rate 140/min
D. Respiratory rate 52/min
A nurse is teaching a postpartum client about preventing mastitis. Which of the following
statements indicates a need for further teaching?
✔✔A. “I will stop breastfeeding if my breasts get sore.”
B. “I will let my baby fully empty one breast before switching.”
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, C. “I will wear a supportive bra.”
D. “I will wash my hands before feeding.”
A nurse is caring for a client receiving magnesium sulfate for preeclampsia. Which finding
requires immediate intervention?
✔✔A. Respiratory rate of 10/min
B. Urine output of 35 mL/hr
C. 1+ deep tendon reflexes
D. Sedated appearance
A newborn is found to have a low-set ear and a single palmar crease. What is the appropriate
nursing action?
A. Perform chest physiotherapy
B. Prepare for phototherapy
✔✔C. Notify the provider for possible genetic evaluation
D. Feed the infant immediately
A nurse is assessing a newborn with suspected neonatal abstinence syndrome. Which of the
following is an expected finding?
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