NUR 254 Maternal & Pediatric Nursing Practice Exam
Exam 1: Maternal-Newborn Nursing (Questions 1-50)
1. A nurse is caring for a client at 38 weeks gestation who reports a sudden gush of
clear fluid from the vagina. Which action should the nurse take first?
• A. Assess the fluid for ferning and pH.
• B. Perform a vaginal exam to check for cervical dilation.
• C. Monitor the fetal heart rate.
• D. Notify the healthcare provider immediately.
Answer: C. Monitor the fetal heart rate.
Rationale: The client is likely experiencing rupture of membranes. The priority action is
to assess fetal well-being by monitoring the fetal heart rate to detect any signs of
distress, such as umbilical cord prolapse.. Assessing the fluid and notifying the provider
are important but secondary to fetal assessment. A vaginal exam should be avoided
until ruptured membranes are confirmed to prevent infection.
2. A newborn is 12 hours old and has not yet passed meconium. Which assessment
finding is most concerning?
• A. The infant is breastfeeding poorly.
• B. The infant's abdomen is firm and distended.
• C. The infant has a heart rate of 140 bpm.
• D. The infant is sleeping soundly.
Answer: B. The infant's abdomen is firm and distended.
Rationale: Failure to pass meconium within the first 24-48 hours can indicate a
gastrointestinal obstruction, such as Hirschsprung's disease or meconium ileus. A firm,
,distended abdomen is a key sign of a potential obstruction. While poor feeding can be a
sign, a distended abdomen is a more specific and concerning physical finding.
3. A nurse is assessing a postpartum client who had a vaginal delivery 2 hours ago.
The nurse notes a heavy, steady trickle of bright red blood from the vagina and a
fundus that is firm and midline at the umbilicus. Which condition should the nurse
suspect?
• A. Uterine atony
• B. Retained placental fragments
• C. Vaginal or cervical lacerations
• D. Normal postpartum lochia
Answer: C. Vaginal or cervical lacerations.
Rationale: A firm, well-contracted uterus (fundus) with bright red, steady bleeding
suggests bleeding from a lower genital tract source, such as a laceration. Uterine atony
would present with a soft, boggy uterus. Retained fragments often cause intermittent
heavy bleeding and a fundus that is not well-contracted.
4. A client at 32 weeks gestation is diagnosed with preeclampsia. Which finding
indicates severe preeclampsia?
• A. Blood pressure of 148/92 mmHg
• B. 1+ proteinuria on a urine dipstick
• C. A headache that is relieved by acetaminophen
• D. Epigastric pain and visual disturbances
Answer: D. Epigastric pain and visual disturbances.
Rationale: Epigastric or right upper quadrant pain and visual disturbances (e.g., blurred
vision, scotomata) are signs of severe preeclampsia, indicating liver capsule swelling and
cerebral edema. A blood pressure of 148/92 mmHg and 1+ proteinuria are consistent
with gestational hypertension or mild preeclampsia but not necessarily severe features.
,5. A client in active labor is requesting pain medication. Her cervix is dilated to 6
cm, and contractions are strong and frequent. Which analgesic is most appropriate
to administer at this time?
• A. Naloxone (Narcan)
• B. Butorphanol (Stadol)
• C. Meperidine (Demerol)
• D. Morphine sulfate
Answer: B. Butorphanol (Stadol).
Rationale: Butorphanol (Stadol) is a mixed opioid agonist-antagonist often used for
pain relief during active labor. It has a ceiling effect for respiratory depression, making it
safer than pure agonists like morphine or meperidine, which can cause significant
neonatal respiratory depression if given too close to delivery. Naloxone is an antagonist
used to reverse opioid effects.
6. A nurse is teaching a postpartum client about breastfeeding. Which instruction
is correct regarding the prevention of mastitis?
• A. Apply warm compresses to the breasts before feeding.
• B. Ensure the infant latches on correctly and empties the breast.
• C. Wash the nipples with soap and water before each feeding.
• D. Limit feeding time to 5 minutes on each breast.
Answer: B. Ensure the infant latches on correctly and empties the breast.
Rationale: Mastitis is often caused by milk stasis and bacterial entry through cracked
nipples. Proper latch and complete emptying of the breast prevent milk stasis. Warm
compresses can help with let-down but don't prevent mastitis. Soap can dry and crack
nipples, and limiting feeding time can lead to engorgement.
7. A newborn has Apgar scores of 7 at 1 minute and 9 at 5 minutes. How should
the nurse interpret these scores?
, • A. The newborn is in severe distress and requires resuscitation.
• B. The newborn is transitioning well and is in stable condition.
• C. The newborn has a moderate acid-base imbalance.
• D. The newborn requires immediate admission to the NICU.
Answer: B. The newborn is transitioning well and is in stable condition.
Rationale: Apgar scores of 7-10 are considered normal and indicate the newborn is
transitioning well to extrauterine life. The improvement from 7 to 9 shows a positive
response to initial interventions. Scores of 4-6 indicate moderate distress, and scores of
0-3 indicate severe distress.
8. A nurse is caring for a client receiving magnesium sulfate for severe
preeclampsia. Which assessment finding indicates magnesium toxicity?
• A. Respiratory rate of 18 breaths/min
• B. Urine output of 40 mL/hr
• C. Deep tendon reflexes (DTRs) of 4+
• D. Absent patellar reflexes
Answer: D. Absent patellar reflexes.
Rationale: Loss of deep tendon reflexes is an early sign of magnesium toxicity. Other
signs include a respiratory rate < 12/min, oliguria (< 30 mL/hr), and a decreased level of
consciousness. The antidote for magnesium toxicity is calcium gluconate.
9. A client at 41 weeks gestation is scheduled for induction of labor with oxytocin
(Pitocin). Which action is most important for the nurse to implement?
• A. Administer the oxytocin as a rapid IV push.
• B. Use a primary IV line for the oxytocin infusion.
• C. Monitor the fetal heart rate and uterine contractions continuously.
• D. Increase the oxytocin rate every 15 minutes until contractions are 2-3 minutes
apart.
Exam 1: Maternal-Newborn Nursing (Questions 1-50)
1. A nurse is caring for a client at 38 weeks gestation who reports a sudden gush of
clear fluid from the vagina. Which action should the nurse take first?
• A. Assess the fluid for ferning and pH.
• B. Perform a vaginal exam to check for cervical dilation.
• C. Monitor the fetal heart rate.
• D. Notify the healthcare provider immediately.
Answer: C. Monitor the fetal heart rate.
Rationale: The client is likely experiencing rupture of membranes. The priority action is
to assess fetal well-being by monitoring the fetal heart rate to detect any signs of
distress, such as umbilical cord prolapse.. Assessing the fluid and notifying the provider
are important but secondary to fetal assessment. A vaginal exam should be avoided
until ruptured membranes are confirmed to prevent infection.
2. A newborn is 12 hours old and has not yet passed meconium. Which assessment
finding is most concerning?
• A. The infant is breastfeeding poorly.
• B. The infant's abdomen is firm and distended.
• C. The infant has a heart rate of 140 bpm.
• D. The infant is sleeping soundly.
Answer: B. The infant's abdomen is firm and distended.
Rationale: Failure to pass meconium within the first 24-48 hours can indicate a
gastrointestinal obstruction, such as Hirschsprung's disease or meconium ileus. A firm,
,distended abdomen is a key sign of a potential obstruction. While poor feeding can be a
sign, a distended abdomen is a more specific and concerning physical finding.
3. A nurse is assessing a postpartum client who had a vaginal delivery 2 hours ago.
The nurse notes a heavy, steady trickle of bright red blood from the vagina and a
fundus that is firm and midline at the umbilicus. Which condition should the nurse
suspect?
• A. Uterine atony
• B. Retained placental fragments
• C. Vaginal or cervical lacerations
• D. Normal postpartum lochia
Answer: C. Vaginal or cervical lacerations.
Rationale: A firm, well-contracted uterus (fundus) with bright red, steady bleeding
suggests bleeding from a lower genital tract source, such as a laceration. Uterine atony
would present with a soft, boggy uterus. Retained fragments often cause intermittent
heavy bleeding and a fundus that is not well-contracted.
4. A client at 32 weeks gestation is diagnosed with preeclampsia. Which finding
indicates severe preeclampsia?
• A. Blood pressure of 148/92 mmHg
• B. 1+ proteinuria on a urine dipstick
• C. A headache that is relieved by acetaminophen
• D. Epigastric pain and visual disturbances
Answer: D. Epigastric pain and visual disturbances.
Rationale: Epigastric or right upper quadrant pain and visual disturbances (e.g., blurred
vision, scotomata) are signs of severe preeclampsia, indicating liver capsule swelling and
cerebral edema. A blood pressure of 148/92 mmHg and 1+ proteinuria are consistent
with gestational hypertension or mild preeclampsia but not necessarily severe features.
,5. A client in active labor is requesting pain medication. Her cervix is dilated to 6
cm, and contractions are strong and frequent. Which analgesic is most appropriate
to administer at this time?
• A. Naloxone (Narcan)
• B. Butorphanol (Stadol)
• C. Meperidine (Demerol)
• D. Morphine sulfate
Answer: B. Butorphanol (Stadol).
Rationale: Butorphanol (Stadol) is a mixed opioid agonist-antagonist often used for
pain relief during active labor. It has a ceiling effect for respiratory depression, making it
safer than pure agonists like morphine or meperidine, which can cause significant
neonatal respiratory depression if given too close to delivery. Naloxone is an antagonist
used to reverse opioid effects.
6. A nurse is teaching a postpartum client about breastfeeding. Which instruction
is correct regarding the prevention of mastitis?
• A. Apply warm compresses to the breasts before feeding.
• B. Ensure the infant latches on correctly and empties the breast.
• C. Wash the nipples with soap and water before each feeding.
• D. Limit feeding time to 5 minutes on each breast.
Answer: B. Ensure the infant latches on correctly and empties the breast.
Rationale: Mastitis is often caused by milk stasis and bacterial entry through cracked
nipples. Proper latch and complete emptying of the breast prevent milk stasis. Warm
compresses can help with let-down but don't prevent mastitis. Soap can dry and crack
nipples, and limiting feeding time can lead to engorgement.
7. A newborn has Apgar scores of 7 at 1 minute and 9 at 5 minutes. How should
the nurse interpret these scores?
, • A. The newborn is in severe distress and requires resuscitation.
• B. The newborn is transitioning well and is in stable condition.
• C. The newborn has a moderate acid-base imbalance.
• D. The newborn requires immediate admission to the NICU.
Answer: B. The newborn is transitioning well and is in stable condition.
Rationale: Apgar scores of 7-10 are considered normal and indicate the newborn is
transitioning well to extrauterine life. The improvement from 7 to 9 shows a positive
response to initial interventions. Scores of 4-6 indicate moderate distress, and scores of
0-3 indicate severe distress.
8. A nurse is caring for a client receiving magnesium sulfate for severe
preeclampsia. Which assessment finding indicates magnesium toxicity?
• A. Respiratory rate of 18 breaths/min
• B. Urine output of 40 mL/hr
• C. Deep tendon reflexes (DTRs) of 4+
• D. Absent patellar reflexes
Answer: D. Absent patellar reflexes.
Rationale: Loss of deep tendon reflexes is an early sign of magnesium toxicity. Other
signs include a respiratory rate < 12/min, oliguria (< 30 mL/hr), and a decreased level of
consciousness. The antidote for magnesium toxicity is calcium gluconate.
9. A client at 41 weeks gestation is scheduled for induction of labor with oxytocin
(Pitocin). Which action is most important for the nurse to implement?
• A. Administer the oxytocin as a rapid IV push.
• B. Use a primary IV line for the oxytocin infusion.
• C. Monitor the fetal heart rate and uterine contractions continuously.
• D. Increase the oxytocin rate every 15 minutes until contractions are 2-3 minutes
apart.
