MATERNITY CJE EXAM – QUESTIONS AND ANSWERS |
VERIFIED AND WELL DETAILED ANSWERS PLUS RATIONALES |
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1. A primigravida at 38 weeks gestation presents to the labor and delivery unit reporting
regular uterine contractions every 4 minutes lasting for 50 seconds. Her cervix is 4 cm
dilated, 80% effaced, and the presenting part is at station 0. Which phase of the first stage
of labor is this client currently experiencing?
A. Latent phase
B. Active phase
C. Transition phase
D. Second stage of labor
Rationale: The active phase of the first stage of labor is characterized by regular, strong
contractions and cervical dilation from 6 cm (historically beginning at 4 cm per traditional
guidelines) to 10 cm, with progressive effacement and fetal descent. The latent phase involves
milder contractions and dilation up to 3 to 5 cm. The transition phase spans from 8 cm to 10
cm dilation with intense contractions. The second stage begins at complete cervical dilation.
2. A postpartum client on her second postpartum day reports moderate lochia rubra and
mild afterpains during breastfeeding. Assessment reveals a firm, midline uterine fundus
located two centimeters below the umbilicus. What is the most appropriate nursing action
at this time?
A. Administer methylergonovine as prescribed immediately
B. Document the normal physiological finding and continue routine monitoring
C. Catheterize the client to relieve potential bladder distention
D. Massage the uterine fundus vigorously until it becomes boggy
Rationale: A firm, midline fundus located below the umbilicus on postpartum day two
indicates normal uterine involution. Mild afterpains during breastfeeding are expected due to
oxytocin release causing uterine contractions. Methylergonovine, catheterization, and
vigorous massage are unnecessary and contraindicated for a normal, contracted uterus.
3. During a routine prenatal visit at 28 weeks gestation, a client who is Rh-negative and
unsensitized has an antibody screen (indirect Coombs test) reported as negative. What is
the standard clinical management for this client?
,A. Administer Rho(D) immune globulin immediately and repeat the titer in 4 weeks
B. Schedule the administration of Rho(D) immune globulin at 36 weeks gestation
C. Administer Rho(D) immune globulin at 28 weeks gestation and within 72 hours of delivery if the
infant is Rh-positive
D. Withhold Rho(D) immune globulin until after delivery confirmation of the infant's blood type
Rationale: Standard protocol for an unsensitized Rh-negative client involves routine
prophylactic administration of Rho(D) immune globulin at 28 weeks gestation to prevent
maternal sensitization, followed by another dose postpartum if the newborn is confirmed Rh-
positive. Waiting until delivery misses the prophylactic window during the third trimester.
4. A nurse is caring for a client in active labor who receives an epidural analgesia block.
Shortly after placement, the client's blood pressure drops from 120/80 mm Hg to 88/50 mm
Hg, and the fetal heart rate tracing reveals late decelerations. Which immediate
intervention should the nurse perform first?
A. Administer IV labetalol to stabilize maternal vascular tone
B. Place the client in a lateral position and administer IV fluid bolus
C. Prepare the client for an emergency cesarean delivery within 5 minutes
D. Turn off the oxytocin infusion and apply supplemental oxygen via nasal cannula
Rationale: Maternal hypotension secondary to sympathetic blockade from an epidural
requires immediate lateral positioning to relieve aortocaval compression, alongside rapid
intravenous fluid administration to restore vascular volume and correct uteroplacental
perfusion. While oxytocin might be stopped if hyperstimulation is present, treating the primary
cause of hypotension is the immediate priority.
5. A postpartum client expresses extreme sadness, frequent crying spells, difficulty
sleeping, and anxiety that began three days after delivering her healthy term infant. She
states she feels overwhelmed by motherhood. Which condition do these symptoms most
accurately reflect?
A. Postpartum psychosis
B. Postpartum blues
C. Major postpartum depression
D. Bipolar disorder type II
Rationale: Postpartum blues is a transient, self-limiting condition affecting up to 80% of new
mothers within the first few days to weeks postpartum, characterized by tearfulness, mood
, lability, and anxiety, resolving without formal psychiatric intervention. Major postpartum
depression and psychosis are more severe, persistent, and require medical intervention.
6. A client at 34 weeks gestation is admitted with suspected placenta previa. Which
diagnostic procedure or assessment technique is strictly contraindicated for this client?
A. Transabdominal ultrasound examination
B. Electronic fetal heart rate monitoring
C. Sterile speculum examination of the cervix
D. Digital vaginal examination
Rationale: Digital vaginal examination is strictly contraindicated in the presence of known or
suspected placenta previa because palpation of the placenta through the cervical os can
disrupt placental blood vessels, precipitating severe, life-threatening hemorrhage for both
mother and fetus.
7. A nurse assesses a newborn infant one minute after birth. The infant has a heart rate of
140 beats per minute, cries vigorously upon stimulation, demonstrates active movement of
all extremities, has a completely pink body and extremities, and withdraws the feet when
stimulated. What is the correct Apgar score for this newborn?
A. 7
B. 8
C. 9
D. 10
Rationale: The Apgar scoring system evaluates five criteria: heart rate (over 100 bpm = 2),
respiratory effort (vigorous cry = 2), muscle tone (active movement = 2), reflex irritability
(vigorous cry/withdrawal = 2), and color (completely pink = 2). Totaling these yields a score of
10.
8. A client with gestational hypertension at 38 weeks gestation is receiving an intravenous
infusion of magnesium sulfate for seizure prophylaxis. Which clinical finding indicates the
development of magnesium toxicity requiring immediate cessation of the infusion?
A. Respiratory rate of 10 breaths per minute
B. Deep tendon reflexes rated as 2+
C. Serum magnesium level of 6.0 mg/dL
D. Urine output of 45 mL per hour
VERIFIED AND WELL DETAILED ANSWERS PLUS RATIONALES |
GUARANTEED PASS | LATEST EXAM UPDATE | EXAM PREP |
STUDY GUIDE | PRACTICE TEST| DOWNLOAD INSTANT PDF
1. A primigravida at 38 weeks gestation presents to the labor and delivery unit reporting
regular uterine contractions every 4 minutes lasting for 50 seconds. Her cervix is 4 cm
dilated, 80% effaced, and the presenting part is at station 0. Which phase of the first stage
of labor is this client currently experiencing?
A. Latent phase
B. Active phase
C. Transition phase
D. Second stage of labor
Rationale: The active phase of the first stage of labor is characterized by regular, strong
contractions and cervical dilation from 6 cm (historically beginning at 4 cm per traditional
guidelines) to 10 cm, with progressive effacement and fetal descent. The latent phase involves
milder contractions and dilation up to 3 to 5 cm. The transition phase spans from 8 cm to 10
cm dilation with intense contractions. The second stage begins at complete cervical dilation.
2. A postpartum client on her second postpartum day reports moderate lochia rubra and
mild afterpains during breastfeeding. Assessment reveals a firm, midline uterine fundus
located two centimeters below the umbilicus. What is the most appropriate nursing action
at this time?
A. Administer methylergonovine as prescribed immediately
B. Document the normal physiological finding and continue routine monitoring
C. Catheterize the client to relieve potential bladder distention
D. Massage the uterine fundus vigorously until it becomes boggy
Rationale: A firm, midline fundus located below the umbilicus on postpartum day two
indicates normal uterine involution. Mild afterpains during breastfeeding are expected due to
oxytocin release causing uterine contractions. Methylergonovine, catheterization, and
vigorous massage are unnecessary and contraindicated for a normal, contracted uterus.
3. During a routine prenatal visit at 28 weeks gestation, a client who is Rh-negative and
unsensitized has an antibody screen (indirect Coombs test) reported as negative. What is
the standard clinical management for this client?
,A. Administer Rho(D) immune globulin immediately and repeat the titer in 4 weeks
B. Schedule the administration of Rho(D) immune globulin at 36 weeks gestation
C. Administer Rho(D) immune globulin at 28 weeks gestation and within 72 hours of delivery if the
infant is Rh-positive
D. Withhold Rho(D) immune globulin until after delivery confirmation of the infant's blood type
Rationale: Standard protocol for an unsensitized Rh-negative client involves routine
prophylactic administration of Rho(D) immune globulin at 28 weeks gestation to prevent
maternal sensitization, followed by another dose postpartum if the newborn is confirmed Rh-
positive. Waiting until delivery misses the prophylactic window during the third trimester.
4. A nurse is caring for a client in active labor who receives an epidural analgesia block.
Shortly after placement, the client's blood pressure drops from 120/80 mm Hg to 88/50 mm
Hg, and the fetal heart rate tracing reveals late decelerations. Which immediate
intervention should the nurse perform first?
A. Administer IV labetalol to stabilize maternal vascular tone
B. Place the client in a lateral position and administer IV fluid bolus
C. Prepare the client for an emergency cesarean delivery within 5 minutes
D. Turn off the oxytocin infusion and apply supplemental oxygen via nasal cannula
Rationale: Maternal hypotension secondary to sympathetic blockade from an epidural
requires immediate lateral positioning to relieve aortocaval compression, alongside rapid
intravenous fluid administration to restore vascular volume and correct uteroplacental
perfusion. While oxytocin might be stopped if hyperstimulation is present, treating the primary
cause of hypotension is the immediate priority.
5. A postpartum client expresses extreme sadness, frequent crying spells, difficulty
sleeping, and anxiety that began three days after delivering her healthy term infant. She
states she feels overwhelmed by motherhood. Which condition do these symptoms most
accurately reflect?
A. Postpartum psychosis
B. Postpartum blues
C. Major postpartum depression
D. Bipolar disorder type II
Rationale: Postpartum blues is a transient, self-limiting condition affecting up to 80% of new
mothers within the first few days to weeks postpartum, characterized by tearfulness, mood
, lability, and anxiety, resolving without formal psychiatric intervention. Major postpartum
depression and psychosis are more severe, persistent, and require medical intervention.
6. A client at 34 weeks gestation is admitted with suspected placenta previa. Which
diagnostic procedure or assessment technique is strictly contraindicated for this client?
A. Transabdominal ultrasound examination
B. Electronic fetal heart rate monitoring
C. Sterile speculum examination of the cervix
D. Digital vaginal examination
Rationale: Digital vaginal examination is strictly contraindicated in the presence of known or
suspected placenta previa because palpation of the placenta through the cervical os can
disrupt placental blood vessels, precipitating severe, life-threatening hemorrhage for both
mother and fetus.
7. A nurse assesses a newborn infant one minute after birth. The infant has a heart rate of
140 beats per minute, cries vigorously upon stimulation, demonstrates active movement of
all extremities, has a completely pink body and extremities, and withdraws the feet when
stimulated. What is the correct Apgar score for this newborn?
A. 7
B. 8
C. 9
D. 10
Rationale: The Apgar scoring system evaluates five criteria: heart rate (over 100 bpm = 2),
respiratory effort (vigorous cry = 2), muscle tone (active movement = 2), reflex irritability
(vigorous cry/withdrawal = 2), and color (completely pink = 2). Totaling these yields a score of
10.
8. A client with gestational hypertension at 38 weeks gestation is receiving an intravenous
infusion of magnesium sulfate for seizure prophylaxis. Which clinical finding indicates the
development of magnesium toxicity requiring immediate cessation of the infusion?
A. Respiratory rate of 10 breaths per minute
B. Deep tendon reflexes rated as 2+
C. Serum magnesium level of 6.0 mg/dL
D. Urine output of 45 mL per hour
