NCLEX Maternal Health
70 Practice Questions with Answers and Rationales
Question 1
A nurse is assessing a client who is 38 weeks pregnant and reports a sudden gush of fluid from the
vagina. Which action should the nurse take first?
A. Perform a vaginal examination
B. Check the fetal heart rate ✓
C. Notify the healthcare provider
D. Assess the fluid using nitrazine paper
■ Correct Answer: B
Rationale: The priority action is to assess fetal well-being by checking the fetal heart rate. A sudden gush
of fluid may indicate rupture of membranes, which can lead to umbilical cord prolapse. Fetal heart rate
assessment determines if the fetus is in distress. A vaginal examination should be avoided until cord
prolapse is ruled out.
Question 2
A nurse is caring for a client in active labor. The fetal heart rate monitor shows late decelerations. Which
action should the nurse take first?
A. Administer oxygen via face mask at 8–10 L/min
B. Reposition the client to the left lateral position ✓
C. Increase the IV fluid rate
D. Notify the healthcare provider immediately
■ Correct Answer: B
Rationale: Late decelerations indicate uteroplacental insufficiency. The first action is to reposition the client
to the left lateral position to relieve pressure on the vena cava and improve placental perfusion. Subsequent
interventions include administering oxygen, increasing IV fluids, and notifying the provider if decelerations
persist.
Question 3
A client at 28 weeks gestation reports severe headache, blurred vision, and right upper quadrant pain. Her
blood pressure is 158/110 mmHg. The nurse suspects which condition?
A. Gestational hypertension
B. Preeclampsia with severe features ✓
C. Eclampsia
D. HELLP syndrome
■ Correct Answer: B
, Rationale: The client's symptoms — severe headache, blurred vision, RUQ pain, and BP ≥160/110 mmHg
— indicate preeclampsia with severe features. HELLP syndrome also includes these symptoms but
requires lab confirmation (hemolysis, elevated liver enzymes, low platelets). Eclampsia involves seizures,
which are not yet present.
Question 4
A nurse is preparing to administer magnesium sulfate to a client with severe preeclampsia. Which
assessment finding requires the nurse to withhold the medication?
A. Blood pressure of 156/104 mmHg
B. Respiratory rate of 10 breaths per minute ✓
C. Urine output of 35 mL/hr
D. Deep tendon reflexes of 2+
■ Correct Answer: B
Rationale: Magnesium sulfate is a CNS depressant used to prevent seizures in preeclampsia. A
respiratory rate below 12 breaths per minute indicates magnesium toxicity and the medication must be
withheld. The antidote is calcium gluconate. Urine output should be at least 25–30 mL/hr, and DTRs should
be present (not absent) before administering.
Question 5
A client is in the second stage of labor. The nurse observes the umbilical cord protruding from the vagina.
What is the priority nursing action?
A. Place the client in Trendelenburg or knee-chest position ✓
B. Gently push the cord back into the vagina
C. Prepare for immediate vaginal delivery
D. Administer oxygen at 2 L/min via nasal cannula
■ Correct Answer: A
Rationale: Cord prolapse is an obstetric emergency. The priority is to relieve pressure on the cord to
maintain fetal oxygenation. Placing the client in Trendelenburg or knee-chest position uses gravity to
reduce compression. The nurse should also manually hold the presenting part off the cord, administer
high-flow oxygen, and prepare for emergency cesarean delivery. The cord should never be pushed back in.
Question 6
A client who is 36 weeks pregnant is admitted with painless, bright red vaginal bleeding. The nurse
suspects which condition?
A. Abruptio placentae
B. Placenta previa ✓
C. Preterm labor
D. Bloody show
, ■ Correct Answer: B
Rationale: Placenta previa presents with painless, bright red vaginal bleeding in the second or third
trimester due to the placenta covering the cervical os. Abruptio placentae typically presents with painful,
dark red bleeding and a rigid, board-like abdomen. Vaginal examination is contraindicated in suspected
placenta previa.
Question 7
A postpartum client is assessed and found to have a fundus that is boggy and displaced to the right of
midline. What is the most likely cause?
A. Uterine atony
B. Full bladder ✓
C. Normal postpartum involution
D. Retained placental fragments
■ Correct Answer: B
Rationale: A fundus that is boggy AND displaced to one side (usually the right) indicates a full bladder. The
distended bladder pushes the uterus out of midline and prevents proper uterine contraction. The priority
intervention is to have the client void or insert a urinary catheter. If the fundus remains boggy after bladder
emptying, uterine atony is the concern.
Question 8
A nurse is assessing a newborn immediately after delivery. Which finding requires immediate
intervention?
A. Heart rate of 110 beats per minute
B. Acrocyanosis
C. Respiratory rate of 56 breaths per minute
D. Absence of spontaneous breathing at 1 minute ✓
■ Correct Answer: D
Rationale: Absence of spontaneous breathing at 1 minute of life requires immediate resuscitation,
including stimulation, positioning, and positive pressure ventilation if needed. Acrocyanosis (bluish hands
and feet) is normal in newborns. A heart rate of 110 bpm and respiratory rate of 56 breaths/min are within
normal neonatal ranges.
Question 9
A nurse is teaching a pregnant client about signs of preterm labor. Which statement by the client indicates
understanding?
A. 'I should call the doctor if I feel more than 4 contractions in one hour before 37 weeks.' ✓
B. 'Braxton Hicks contractions are a sign I am going into labor early.'
C. 'Increased vaginal discharge is normal and nothing to worry about.'
D. 'Low back pain is only a concern after my due date.'
70 Practice Questions with Answers and Rationales
Question 1
A nurse is assessing a client who is 38 weeks pregnant and reports a sudden gush of fluid from the
vagina. Which action should the nurse take first?
A. Perform a vaginal examination
B. Check the fetal heart rate ✓
C. Notify the healthcare provider
D. Assess the fluid using nitrazine paper
■ Correct Answer: B
Rationale: The priority action is to assess fetal well-being by checking the fetal heart rate. A sudden gush
of fluid may indicate rupture of membranes, which can lead to umbilical cord prolapse. Fetal heart rate
assessment determines if the fetus is in distress. A vaginal examination should be avoided until cord
prolapse is ruled out.
Question 2
A nurse is caring for a client in active labor. The fetal heart rate monitor shows late decelerations. Which
action should the nurse take first?
A. Administer oxygen via face mask at 8–10 L/min
B. Reposition the client to the left lateral position ✓
C. Increase the IV fluid rate
D. Notify the healthcare provider immediately
■ Correct Answer: B
Rationale: Late decelerations indicate uteroplacental insufficiency. The first action is to reposition the client
to the left lateral position to relieve pressure on the vena cava and improve placental perfusion. Subsequent
interventions include administering oxygen, increasing IV fluids, and notifying the provider if decelerations
persist.
Question 3
A client at 28 weeks gestation reports severe headache, blurred vision, and right upper quadrant pain. Her
blood pressure is 158/110 mmHg. The nurse suspects which condition?
A. Gestational hypertension
B. Preeclampsia with severe features ✓
C. Eclampsia
D. HELLP syndrome
■ Correct Answer: B
, Rationale: The client's symptoms — severe headache, blurred vision, RUQ pain, and BP ≥160/110 mmHg
— indicate preeclampsia with severe features. HELLP syndrome also includes these symptoms but
requires lab confirmation (hemolysis, elevated liver enzymes, low platelets). Eclampsia involves seizures,
which are not yet present.
Question 4
A nurse is preparing to administer magnesium sulfate to a client with severe preeclampsia. Which
assessment finding requires the nurse to withhold the medication?
A. Blood pressure of 156/104 mmHg
B. Respiratory rate of 10 breaths per minute ✓
C. Urine output of 35 mL/hr
D. Deep tendon reflexes of 2+
■ Correct Answer: B
Rationale: Magnesium sulfate is a CNS depressant used to prevent seizures in preeclampsia. A
respiratory rate below 12 breaths per minute indicates magnesium toxicity and the medication must be
withheld. The antidote is calcium gluconate. Urine output should be at least 25–30 mL/hr, and DTRs should
be present (not absent) before administering.
Question 5
A client is in the second stage of labor. The nurse observes the umbilical cord protruding from the vagina.
What is the priority nursing action?
A. Place the client in Trendelenburg or knee-chest position ✓
B. Gently push the cord back into the vagina
C. Prepare for immediate vaginal delivery
D. Administer oxygen at 2 L/min via nasal cannula
■ Correct Answer: A
Rationale: Cord prolapse is an obstetric emergency. The priority is to relieve pressure on the cord to
maintain fetal oxygenation. Placing the client in Trendelenburg or knee-chest position uses gravity to
reduce compression. The nurse should also manually hold the presenting part off the cord, administer
high-flow oxygen, and prepare for emergency cesarean delivery. The cord should never be pushed back in.
Question 6
A client who is 36 weeks pregnant is admitted with painless, bright red vaginal bleeding. The nurse
suspects which condition?
A. Abruptio placentae
B. Placenta previa ✓
C. Preterm labor
D. Bloody show
, ■ Correct Answer: B
Rationale: Placenta previa presents with painless, bright red vaginal bleeding in the second or third
trimester due to the placenta covering the cervical os. Abruptio placentae typically presents with painful,
dark red bleeding and a rigid, board-like abdomen. Vaginal examination is contraindicated in suspected
placenta previa.
Question 7
A postpartum client is assessed and found to have a fundus that is boggy and displaced to the right of
midline. What is the most likely cause?
A. Uterine atony
B. Full bladder ✓
C. Normal postpartum involution
D. Retained placental fragments
■ Correct Answer: B
Rationale: A fundus that is boggy AND displaced to one side (usually the right) indicates a full bladder. The
distended bladder pushes the uterus out of midline and prevents proper uterine contraction. The priority
intervention is to have the client void or insert a urinary catheter. If the fundus remains boggy after bladder
emptying, uterine atony is the concern.
Question 8
A nurse is assessing a newborn immediately after delivery. Which finding requires immediate
intervention?
A. Heart rate of 110 beats per minute
B. Acrocyanosis
C. Respiratory rate of 56 breaths per minute
D. Absence of spontaneous breathing at 1 minute ✓
■ Correct Answer: D
Rationale: Absence of spontaneous breathing at 1 minute of life requires immediate resuscitation,
including stimulation, positioning, and positive pressure ventilation if needed. Acrocyanosis (bluish hands
and feet) is normal in newborns. A heart rate of 110 bpm and respiratory rate of 56 breaths/min are within
normal neonatal ranges.
Question 9
A nurse is teaching a pregnant client about signs of preterm labor. Which statement by the client indicates
understanding?
A. 'I should call the doctor if I feel more than 4 contractions in one hour before 37 weeks.' ✓
B. 'Braxton Hicks contractions are a sign I am going into labor early.'
C. 'Increased vaginal discharge is normal and nothing to worry about.'
D. 'Low back pain is only a concern after my due date.'
