Test Bank For Safe Maternity and Pediatric
Nursing Care 3rd Edition by Luanne Linnard-
Palmer Gloria
MATERNITY NURSING
1. A patient in active labor is requesting pain relief. Which statement indicates
the patient understands the effects of systemic analgesia on the fetus?
A) "The medication will completely eliminate all pain sensation during
contractions."
B) "The medication may cause temporary respiratory depression in my baby after
birth."
C) "The medication is safe to take at any time during labor without side effects."
D) "The medication will cause permanent neurological damage to my baby."
Correct Answer: B
Rationale: Systemic opioids cross the placenta and can cause neonatal respiratory
depression, especially if given close to delivery. They do not completely eliminate
pain (A), are not safe at any time without risk (C), and do not cause permanent
neurological damage (D) when used appropriately.
2. A nurse is assessing a patient at 36 weeks gestation. Which finding should be
reported to the healthcare provider immediately?
A) Mild ankle edema
B) Braxton-Hicks contractions every 20 minutes
C) Blood pressure of 148/94 mmHg
D) Weight gain of 1 pound in one week
Correct Answer: C
Rationale: A blood pressure of 148/94 mmHg indicates possible preeclampsia or
gestational hypertension, which requires immediate evaluation. Mild ankle edema
(A), Braxton-Hicks (B), and 1-pound weekly weight gain (D) are normal findings in
the third trimester.
,3. The nurse is caring for a patient receiving magnesium sulfate for severe
preeclampsia. Which assessment finding indicates magnesium toxicity?
A) Deep tendon reflexes 2+
B) Urinary output of 40 mL/hr
C) Respiratory rate of 10 breaths/min
D) Serum magnesium level of 5 mEq/L
Correct Answer: C
Rationale: A respiratory rate below 12 breaths/min is a sign of magnesium
toxicity. Normal reflexes are 1-2+ (A), normal urinary output is >30 mL/hr (B), and
a therapeutic magnesium level is 4-7 mEq/L (D), so 5 mEq/L is within range.
4. A patient at 39 weeks gestation presents with a gush of fluid from the vagina.
Which action should the nurse take first?
A) Perform a vaginal exam to check dilation
B) Assess the fluid for color, odor, and amount
C) Administer oxytocin to induce labor
D) Prepare the patient for an immediate cesarean section
Correct Answer: B
Rationale: The nurse should first assess the amniotic fluid for meconium (greenish
color) or foul odor (infection). A vaginal exam (A) increases infection risk after
rupture; oxytocin (C) is not given without a provider order; C-section (D) is not
indicated unless complications arise.
5. A patient in the first stage of labor is experiencing hyperventilation due to
pain. Which symptom is most consistent with hyperventilation?
A) Numbness and tingling of the fingers
B) Increased blood pressure
C) Decreased respiratory rate
D) Flushing of the skin
,Correct Answer: A
Rationale: Hyperventilation causes respiratory alkalosis, leading to numbness and
tingling (paresthesia) in the fingers and around the mouth. It typically causes
a decrease in BP (not B), an increase in respiratory rate (not C), and pallor or
cyanosis (not D).
6. The nurse is monitoring a fetal heart rate (FHR) and notes late decelerations.
What is the priority nursing action?
A) Increase the rate of IV fluids
B) Position the patient on her left side
C) Administer oxygen via face mask at 2 L/min
D) Prepare for an amnioinfusion
Correct Answer: B
Rationale: The priority action for late decelerations (indicating uteroplacental
insufficiency) is to position the patient on her left side to increase uterine blood
flow. After repositioning, the nurse would then increase IV fluids (A) and apply
oxygen at 8-10 L/min (not 2 L) (C). Amnioinfusion (D) is for variable decelerations.
7. A postpartum patient reports heavy lochia with large clots and a fundus that
is boggy and deviated to the right. What is the most likely cause?
A) Uterine atony
B) Full bladder
C) Retained placental fragments
D) Uterine inversion
Correct Answer: B
Rationale: A boggy fundus deviated to the right indicates a full bladder displacing
the uterus, which prevents effective contraction and leads to bleeding. The
priority is to have the patient void. Uterine atony (A) is the result, not the cause;
retained fragments (C) cause subinvolution; inversion (D) is a rare emergency.
, 8. A patient with gestational diabetes is scheduled for a non-stress test (NST).
Which result is considered reactive (reassuring)?
A) Two accelerations of FHR of 20 bpm lasting 10 seconds in 20 minutes
B) No accelerations in 40 minutes
C) Late decelerations with 50% of contractions
D) Variable decelerations lasting 60 seconds
Correct Answer: A
Rationale: A reactive NST requires two accelerations of at least 15 bpm (or 10
bpm if <32 weeks) lasting at least 15 seconds in a 20-minute period. No
accelerations (B) is non-reactive; late (C) and variable (D) decelerations are
abnormal findings.
9. The nurse is teaching a breastfeeding patient about mastitis prevention.
Which statement indicates correct understanding?
A) "I should feed my baby on a strict 4-hour schedule."
B) "I should completely empty one breast before switching to the other."
C) "I should apply heat to my breasts for 20 minutes after feeding."
D) "I should stop breastfeeding if I develop a fever."
Correct Answer: B
Rationale: Complete emptying of one breast prevents milk stasis, which leads to
mastitis. Feeding should be on demand (not strict schedules - A). Heat is
applied before feeding, not after (C). Breastfeeding should continue even with
mastitis to clear the infection (D).
10. A patient is 10 cm dilated and feels an urge to push. The fetus is at +2
station. Which phase of labor is this?
A) Latent phase of first stage
B) Active phase of first stage
C) Transition phase of first stage
D) Second stage of labor
Correct Answer: D
Nursing Care 3rd Edition by Luanne Linnard-
Palmer Gloria
MATERNITY NURSING
1. A patient in active labor is requesting pain relief. Which statement indicates
the patient understands the effects of systemic analgesia on the fetus?
A) "The medication will completely eliminate all pain sensation during
contractions."
B) "The medication may cause temporary respiratory depression in my baby after
birth."
C) "The medication is safe to take at any time during labor without side effects."
D) "The medication will cause permanent neurological damage to my baby."
Correct Answer: B
Rationale: Systemic opioids cross the placenta and can cause neonatal respiratory
depression, especially if given close to delivery. They do not completely eliminate
pain (A), are not safe at any time without risk (C), and do not cause permanent
neurological damage (D) when used appropriately.
2. A nurse is assessing a patient at 36 weeks gestation. Which finding should be
reported to the healthcare provider immediately?
A) Mild ankle edema
B) Braxton-Hicks contractions every 20 minutes
C) Blood pressure of 148/94 mmHg
D) Weight gain of 1 pound in one week
Correct Answer: C
Rationale: A blood pressure of 148/94 mmHg indicates possible preeclampsia or
gestational hypertension, which requires immediate evaluation. Mild ankle edema
(A), Braxton-Hicks (B), and 1-pound weekly weight gain (D) are normal findings in
the third trimester.
,3. The nurse is caring for a patient receiving magnesium sulfate for severe
preeclampsia. Which assessment finding indicates magnesium toxicity?
A) Deep tendon reflexes 2+
B) Urinary output of 40 mL/hr
C) Respiratory rate of 10 breaths/min
D) Serum magnesium level of 5 mEq/L
Correct Answer: C
Rationale: A respiratory rate below 12 breaths/min is a sign of magnesium
toxicity. Normal reflexes are 1-2+ (A), normal urinary output is >30 mL/hr (B), and
a therapeutic magnesium level is 4-7 mEq/L (D), so 5 mEq/L is within range.
4. A patient at 39 weeks gestation presents with a gush of fluid from the vagina.
Which action should the nurse take first?
A) Perform a vaginal exam to check dilation
B) Assess the fluid for color, odor, and amount
C) Administer oxytocin to induce labor
D) Prepare the patient for an immediate cesarean section
Correct Answer: B
Rationale: The nurse should first assess the amniotic fluid for meconium (greenish
color) or foul odor (infection). A vaginal exam (A) increases infection risk after
rupture; oxytocin (C) is not given without a provider order; C-section (D) is not
indicated unless complications arise.
5. A patient in the first stage of labor is experiencing hyperventilation due to
pain. Which symptom is most consistent with hyperventilation?
A) Numbness and tingling of the fingers
B) Increased blood pressure
C) Decreased respiratory rate
D) Flushing of the skin
,Correct Answer: A
Rationale: Hyperventilation causes respiratory alkalosis, leading to numbness and
tingling (paresthesia) in the fingers and around the mouth. It typically causes
a decrease in BP (not B), an increase in respiratory rate (not C), and pallor or
cyanosis (not D).
6. The nurse is monitoring a fetal heart rate (FHR) and notes late decelerations.
What is the priority nursing action?
A) Increase the rate of IV fluids
B) Position the patient on her left side
C) Administer oxygen via face mask at 2 L/min
D) Prepare for an amnioinfusion
Correct Answer: B
Rationale: The priority action for late decelerations (indicating uteroplacental
insufficiency) is to position the patient on her left side to increase uterine blood
flow. After repositioning, the nurse would then increase IV fluids (A) and apply
oxygen at 8-10 L/min (not 2 L) (C). Amnioinfusion (D) is for variable decelerations.
7. A postpartum patient reports heavy lochia with large clots and a fundus that
is boggy and deviated to the right. What is the most likely cause?
A) Uterine atony
B) Full bladder
C) Retained placental fragments
D) Uterine inversion
Correct Answer: B
Rationale: A boggy fundus deviated to the right indicates a full bladder displacing
the uterus, which prevents effective contraction and leads to bleeding. The
priority is to have the patient void. Uterine atony (A) is the result, not the cause;
retained fragments (C) cause subinvolution; inversion (D) is a rare emergency.
, 8. A patient with gestational diabetes is scheduled for a non-stress test (NST).
Which result is considered reactive (reassuring)?
A) Two accelerations of FHR of 20 bpm lasting 10 seconds in 20 minutes
B) No accelerations in 40 minutes
C) Late decelerations with 50% of contractions
D) Variable decelerations lasting 60 seconds
Correct Answer: A
Rationale: A reactive NST requires two accelerations of at least 15 bpm (or 10
bpm if <32 weeks) lasting at least 15 seconds in a 20-minute period. No
accelerations (B) is non-reactive; late (C) and variable (D) decelerations are
abnormal findings.
9. The nurse is teaching a breastfeeding patient about mastitis prevention.
Which statement indicates correct understanding?
A) "I should feed my baby on a strict 4-hour schedule."
B) "I should completely empty one breast before switching to the other."
C) "I should apply heat to my breasts for 20 minutes after feeding."
D) "I should stop breastfeeding if I develop a fever."
Correct Answer: B
Rationale: Complete emptying of one breast prevents milk stasis, which leads to
mastitis. Feeding should be on demand (not strict schedules - A). Heat is
applied before feeding, not after (C). Breastfeeding should continue even with
mastitis to clear the infection (D).
10. A patient is 10 cm dilated and feels an urge to push. The fetus is at +2
station. Which phase of labor is this?
A) Latent phase of first stage
B) Active phase of first stage
C) Transition phase of first stage
D) Second stage of labor
Correct Answer: D
