BSN 366 Exam 4: Comprehensive Practice Exam
300 Questions with Answers and Rationales
SECTION 1: MATERNITY & NEWBORN NURSING
Question 1
A client in active labor experiences prolonged second stage. After the fetal head
delivers, it retracts tightly against the perineum ("turtle sign"). Which action should the
nurse take immediately?
A) Apply gentle suprapubic pressure
B) Position the client in a hands-and-knees position
C) Call for assistance and prepare for shoulder dystocia maneuvers
D) Apply fundal pressure
Answer: C - The "turtle sign" indicates shoulder dystocia, an obstetric emergency. The
nurse should immediately call for assistance and prepare for maneuvers such as
McRoberts' positioning and suprapubic pressure. Fundal pressure is contraindicated as it
may worsen impaction .
Question 2
A client with preeclampsia is receiving a magnesium sulfate infusion. Which assessment
finding indicates magnesium toxicity?
A) Respiratory rate of 16 breaths/min
B) Urine output of 40 mL/hr
C) Absent deep tendon reflexes
D) Serum magnesium level of 5 mEq/L
Answer: C - Absent deep tendon reflexes (DTRs) is a sign of magnesium toxicity. Other
signs include respiratory rate below 12 breaths/min and urine output below 30 mL/hr.
The antidote is calcium gluconate .
,Question 3
A newborn is 2 hours old with a heart rate of 110 bpm, irregular respirations,
acrocyanosis, and a weak cry. What is the priority nursing action?
A) Administer oxygen via hood
B) Stimulate the newborn to cry
C) Assess the newborn's temperature
D) Document the findings
Answer: C - Newborns lose heat rapidly after birth. Cold stress can cause respiratory
distress, hypoglycemia, and metabolic acidosis. The nurse should assess temperature
and provide a warm environment first .
Question 4
A newborn is 12 hours old and has not passed meconium, accompanied by bilious
vomiting and abdominal distention. The nurse should suspect:
A) Normal newborn adaptation
B) Necrotizing enterocolitis
C) Intestinal obstruction
D) Gastroesophageal reflux
Answer: C - Failure to pass meconium within 48 hours, accompanied by bilious emesis
and a distended abdomen, is a classic presentation of intestinal obstruction such as
meconium ileus or Hirschsprung's disease and requires immediate provider notification .
Question 5
An infant of a diabetic mother is at risk for which complication due to hyperinsulinism?
A) Hyperglycemia
B) Hypoglycemia
C) Hypercalcemia
D) Hyperbilirubinemia
,Answer: B - Infants of diabetic mothers (IDM) are at risk for hypoglycemia due to
hyperinsulinemia. The newborn's insulin production continues after birth, leading to low
blood glucose levels. Early feeding and glucose monitoring are essential .
Question 6
The nurse is assessing a client who is receiving oxytocin for induction of labor. Which
finding requires immediate intervention?
A) Contractions every 3 minutes lasting 60 seconds
B) Fetal heart rate of 160 bpm
C) Contractions every 2 minutes lasting 90 seconds
D) Maternal heart rate of 100 bpm
Answer: C - Contractions lasting more than 90 seconds or occurring more frequently
than every 2 minutes indicate uterine hyperstimulation, which can lead to fetal distress
and uterine rupture. The oxytocin should be stopped immediately .
Question 7
A client with gestational diabetes is at risk for which newborn complication?
A) Hyperglycemia
B) Hypoglycemia
C) Hypercalcemia
D) Hyperbilirubinemia
Answer: B - Infants of diabetic mothers are at risk for hypoglycemia due to fetal
hyperinsulinemia. The newborn's insulin production continues after birth, leading to low
blood glucose levels .
Question 8
The nurse is assessing a newborn for jaundice. Which finding indicates pathological
jaundice?
A) Jaundice appearing at 24 hours of age
B) Jaundice appearing at 48 hours of age
, C) Jaundice appearing at 72 hours of age
D) Jaundice appearing at 96 hours of age
Answer: A - Jaundice appearing within the first 24 hours of life is pathological and
requires immediate evaluation. Physiological jaundice typically appears after 24-48
hours .
Question 9
The nurse is teaching a client about breastfeeding. Which instruction is correct?
A) Breastfeeding should be initiated within the first hour after birth
B) Breastfeeding should be delayed until the mother is fully recovered
C) Breastfeeding should be initiated only after the first feeding
D) Breastfeeding should be delayed until the infant cries
Answer: A - Early initiation of breastfeeding within the first hour after birth promotes
bonding, stimulates milk production, and provides colostrum. The infant should be
placed skin-to-skin with the mother as soon as possible after birth .
Question 10
A client with placenta previa is at risk for which complication?
A) Hemorrhage
B) Infection
C) Premature rupture of membranes
D) Preeclampsia
Answer: A - Placenta previa is characterized by the placenta covering the cervical os,
causing painless bleeding during pregnancy and hemorrhage during labor. Clients with
placenta previa are at high risk for hemorrhage .
Question 11
A newborn is 24 hours old and has a bilirubin level of 12 mg/dL. The nurse should:
300 Questions with Answers and Rationales
SECTION 1: MATERNITY & NEWBORN NURSING
Question 1
A client in active labor experiences prolonged second stage. After the fetal head
delivers, it retracts tightly against the perineum ("turtle sign"). Which action should the
nurse take immediately?
A) Apply gentle suprapubic pressure
B) Position the client in a hands-and-knees position
C) Call for assistance and prepare for shoulder dystocia maneuvers
D) Apply fundal pressure
Answer: C - The "turtle sign" indicates shoulder dystocia, an obstetric emergency. The
nurse should immediately call for assistance and prepare for maneuvers such as
McRoberts' positioning and suprapubic pressure. Fundal pressure is contraindicated as it
may worsen impaction .
Question 2
A client with preeclampsia is receiving a magnesium sulfate infusion. Which assessment
finding indicates magnesium toxicity?
A) Respiratory rate of 16 breaths/min
B) Urine output of 40 mL/hr
C) Absent deep tendon reflexes
D) Serum magnesium level of 5 mEq/L
Answer: C - Absent deep tendon reflexes (DTRs) is a sign of magnesium toxicity. Other
signs include respiratory rate below 12 breaths/min and urine output below 30 mL/hr.
The antidote is calcium gluconate .
,Question 3
A newborn is 2 hours old with a heart rate of 110 bpm, irregular respirations,
acrocyanosis, and a weak cry. What is the priority nursing action?
A) Administer oxygen via hood
B) Stimulate the newborn to cry
C) Assess the newborn's temperature
D) Document the findings
Answer: C - Newborns lose heat rapidly after birth. Cold stress can cause respiratory
distress, hypoglycemia, and metabolic acidosis. The nurse should assess temperature
and provide a warm environment first .
Question 4
A newborn is 12 hours old and has not passed meconium, accompanied by bilious
vomiting and abdominal distention. The nurse should suspect:
A) Normal newborn adaptation
B) Necrotizing enterocolitis
C) Intestinal obstruction
D) Gastroesophageal reflux
Answer: C - Failure to pass meconium within 48 hours, accompanied by bilious emesis
and a distended abdomen, is a classic presentation of intestinal obstruction such as
meconium ileus or Hirschsprung's disease and requires immediate provider notification .
Question 5
An infant of a diabetic mother is at risk for which complication due to hyperinsulinism?
A) Hyperglycemia
B) Hypoglycemia
C) Hypercalcemia
D) Hyperbilirubinemia
,Answer: B - Infants of diabetic mothers (IDM) are at risk for hypoglycemia due to
hyperinsulinemia. The newborn's insulin production continues after birth, leading to low
blood glucose levels. Early feeding and glucose monitoring are essential .
Question 6
The nurse is assessing a client who is receiving oxytocin for induction of labor. Which
finding requires immediate intervention?
A) Contractions every 3 minutes lasting 60 seconds
B) Fetal heart rate of 160 bpm
C) Contractions every 2 minutes lasting 90 seconds
D) Maternal heart rate of 100 bpm
Answer: C - Contractions lasting more than 90 seconds or occurring more frequently
than every 2 minutes indicate uterine hyperstimulation, which can lead to fetal distress
and uterine rupture. The oxytocin should be stopped immediately .
Question 7
A client with gestational diabetes is at risk for which newborn complication?
A) Hyperglycemia
B) Hypoglycemia
C) Hypercalcemia
D) Hyperbilirubinemia
Answer: B - Infants of diabetic mothers are at risk for hypoglycemia due to fetal
hyperinsulinemia. The newborn's insulin production continues after birth, leading to low
blood glucose levels .
Question 8
The nurse is assessing a newborn for jaundice. Which finding indicates pathological
jaundice?
A) Jaundice appearing at 24 hours of age
B) Jaundice appearing at 48 hours of age
, C) Jaundice appearing at 72 hours of age
D) Jaundice appearing at 96 hours of age
Answer: A - Jaundice appearing within the first 24 hours of life is pathological and
requires immediate evaluation. Physiological jaundice typically appears after 24-48
hours .
Question 9
The nurse is teaching a client about breastfeeding. Which instruction is correct?
A) Breastfeeding should be initiated within the first hour after birth
B) Breastfeeding should be delayed until the mother is fully recovered
C) Breastfeeding should be initiated only after the first feeding
D) Breastfeeding should be delayed until the infant cries
Answer: A - Early initiation of breastfeeding within the first hour after birth promotes
bonding, stimulates milk production, and provides colostrum. The infant should be
placed skin-to-skin with the mother as soon as possible after birth .
Question 10
A client with placenta previa is at risk for which complication?
A) Hemorrhage
B) Infection
C) Premature rupture of membranes
D) Preeclampsia
Answer: A - Placenta previa is characterized by the placenta covering the cervical os,
causing painless bleeding during pregnancy and hemorrhage during labor. Clients with
placenta previa are at high risk for hemorrhage .
Question 11
A newborn is 24 hours old and has a bilirubin level of 12 mg/dL. The nurse should:
