MATERNAL NEWBORN NURSING
MASTERY ASSESSMENT LEDGER
DETAILED CORRECT ANSWERS WITH
RATIONALES AND CORRECT
VERIFIED ANSWERS FOR A GRADE A+
PERFORMANCE
1. A nurse is reviewing the electronic medical record of a
client who is at 34 weeks of gestation and has a
prescription for a biophysical profile (BPP). The nurse
should identify that which of the following variables is
evaluated as part of this diagnostic prenatal assessment?
A. Maternal serum alpha-fetoprotein level monitored via
maternal venous blood sampling.
B. Fetal breathing movements, amniotic fluid volume, and
fetal tone visualized via ultrasound.
C. Estriol concentrations calculated from a continuous
twenty-four hour maternal urine collection.
D. The percentage of fetal hemoglobin molecules
circulating within the umbilical vein matrix.
Correct Answer: B. Fetal breathing movements,
amniotic fluid volume, and fetal tone visualized
via ultrasound.
Rationale: A biophysical profile (BPP) evaluates fetal
well-being using five specific variables: fetal heart rate
reactivity (via a nonstress test), along with four
ultrasound-monitored variables: fetal breathing
movements, gross body movements, fetal tone, and
qualitative amniotic fluid volume. [1, 2]
2. A nurse is caring for a client who is in the first stage of
labor and has a suspected amniotic fluid embolism
(anaphylactoid syndrome of pregnancy). Which of the
, following clinical findings should the nurse identify as an
immediate priority manifestation of this catastrophic
intrapartum complication?
A. Generalized hyper-reflexia accompanied by continuous
clonus along the patellar tendon axis.
B. Sudden onset of profound respiratory distress, severe
maternal hypotension, and cyanosis.
C. Rapid acceleration of the uterine baseline resting tone
past fifty millimetres of mercury.
D. Sudden development of a bright red macular rash
across the maternal abdominal quadrants.
Correct Answer: B. Sudden onset of profound
respiratory distress, severe maternal
hypotension, and cyanosis.
Rationale: Amniotic fluid embolism occurs when
amniotic fluid, fetal cells, or debris enters maternal
circulation, triggering a severe anaphylactoid response.
This causes acute respiratory distress, cardiovascular
collapse, and disseminated intravascular coagulation
(DIC), demanding emergency life-saving interventions.
[1]
3. A nurse is assessing a postpartum client 4 hours following
a vaginal delivery of a 4,100 g (9 lb 1 oz) newborn. The
nurse notes that the uterine fundus is boggy, displaced
upward, and deviated to the right of the maternal midline.
Which of the following initial actions should the nurse
execute to manage this condition?
A. Administer a high-dose bolus of intramuscular
magnesium sulfate immediately to stabilize myometrial
vectors.
B. Instruct the client to empty their bladder completely, or
prepare to perform an aseptic in-and-out catheterization.
C. Prepare the client for an emergency surgical laparotomy
to investigate internal retroperitoneal hematomas.
, D. Apply a tight, rigid ice pack directly onto the fundal
ridge to induce vasoconstriction.
Correct Answer: B. Instruct the client to empty
their bladder completely, or prepare to perform
an aseptic in-and-out catheterization.
Rationale: A uterine fundus that is boggy, high, and
deviated to the right indicates uterine atony caused by
bladder distention. A full bladder displaces the uterus,
preventing it from contracting properly. Assisting the
client to void or catheterizing them allows the uterus to
contract effectively.
4. A nurse is reviewing laboratory values for a newborn who
is 12 hours old and notes a total serum bilirubin level of 14
mg/dL. The infant is scheduled to begin phototherapy.
Which of the following interventions should the nurse
include in the newborn's plan of care?
A. Apply thick layers of protective zinc oxide ointment
over the newborn's skin to prevent thermal friction burns.
B. Dress the infant in a standard long-sleeve cotton
swaddle blanket to minimize ambient heat energy loss.
C. Cover the newborn's eyes completely with an opaque
safety shield mask and keep them undressed except for a
diaper.
D. Limit the newborn's oral fluid intake to distilled water
exclusively to avoid formula-based protein binds.
Correct Answer: C. Cover the newborn's eyes
completely with an opaque safety shield mask and
keep them undressed except for a diaper.
Rationale: Phototherapy requires maximizing skin
exposure to the therapeutic blue-green light waves to
break down bilirubin. The eyes must be fully protected
with an opaque mask to prevent retinal damage, and skin
assessments must occur regularly. [1, 2]
, 5. A nurse is providing discharge teaching to a client who is
postpartum and has chosen to formula-feed her newborn.
The client reports experiencing severe, painful bilateral
breast engorgement. Which of the following instructions
should the nurse deliver to suppress lactation safely?
A. Massage the breasts under a warm, running shower
stream for twenty minutes twice daily.
B. Use a high-efficiency electric breast pump every two
hours to clear out the milk ducts completely.
C. Wear a snug, supportive sports bra continuously, apply
cold cabbage leaves or ice packs, and avoid breast
stimulation.
D. Express a small amount of colostrum manually onto the
areola area every hour to soothe the skin surface.
Correct Answer: C. Wear a snug, supportive
sports bra continuously, apply cold cabbage leaves
or ice packs, and avoid breast stimulation.
Rationale: For non-nursing mothers, treating
engorgement requires avoiding any form of breast
stimulation or heat, which triggers further prolactin
release. Cold applications, cabbage leaves, and a tight
bra promote vasoconstriction and suppress lactation.
6. A nurse is assessing a pregnant client who is at 32 weeks of
gestation and has been diagnosed with severe
preeclampsia. Which of the following clinical findings
represents a classic sign of worsening disease and central
nervous system irritability?
A. Hypo-reactive deep tendon reflexes recorded at a flat 0
baseline index score.
B. Sudden development of generalized blurred vision, a
persistent frontal headache, and hyper-reflexia with
clonus.
C. A gradual reduction in maternal core body temperature
below ninety-six degrees Fahrenheit.
MASTERY ASSESSMENT LEDGER
DETAILED CORRECT ANSWERS WITH
RATIONALES AND CORRECT
VERIFIED ANSWERS FOR A GRADE A+
PERFORMANCE
1. A nurse is reviewing the electronic medical record of a
client who is at 34 weeks of gestation and has a
prescription for a biophysical profile (BPP). The nurse
should identify that which of the following variables is
evaluated as part of this diagnostic prenatal assessment?
A. Maternal serum alpha-fetoprotein level monitored via
maternal venous blood sampling.
B. Fetal breathing movements, amniotic fluid volume, and
fetal tone visualized via ultrasound.
C. Estriol concentrations calculated from a continuous
twenty-four hour maternal urine collection.
D. The percentage of fetal hemoglobin molecules
circulating within the umbilical vein matrix.
Correct Answer: B. Fetal breathing movements,
amniotic fluid volume, and fetal tone visualized
via ultrasound.
Rationale: A biophysical profile (BPP) evaluates fetal
well-being using five specific variables: fetal heart rate
reactivity (via a nonstress test), along with four
ultrasound-monitored variables: fetal breathing
movements, gross body movements, fetal tone, and
qualitative amniotic fluid volume. [1, 2]
2. A nurse is caring for a client who is in the first stage of
labor and has a suspected amniotic fluid embolism
(anaphylactoid syndrome of pregnancy). Which of the
, following clinical findings should the nurse identify as an
immediate priority manifestation of this catastrophic
intrapartum complication?
A. Generalized hyper-reflexia accompanied by continuous
clonus along the patellar tendon axis.
B. Sudden onset of profound respiratory distress, severe
maternal hypotension, and cyanosis.
C. Rapid acceleration of the uterine baseline resting tone
past fifty millimetres of mercury.
D. Sudden development of a bright red macular rash
across the maternal abdominal quadrants.
Correct Answer: B. Sudden onset of profound
respiratory distress, severe maternal
hypotension, and cyanosis.
Rationale: Amniotic fluid embolism occurs when
amniotic fluid, fetal cells, or debris enters maternal
circulation, triggering a severe anaphylactoid response.
This causes acute respiratory distress, cardiovascular
collapse, and disseminated intravascular coagulation
(DIC), demanding emergency life-saving interventions.
[1]
3. A nurse is assessing a postpartum client 4 hours following
a vaginal delivery of a 4,100 g (9 lb 1 oz) newborn. The
nurse notes that the uterine fundus is boggy, displaced
upward, and deviated to the right of the maternal midline.
Which of the following initial actions should the nurse
execute to manage this condition?
A. Administer a high-dose bolus of intramuscular
magnesium sulfate immediately to stabilize myometrial
vectors.
B. Instruct the client to empty their bladder completely, or
prepare to perform an aseptic in-and-out catheterization.
C. Prepare the client for an emergency surgical laparotomy
to investigate internal retroperitoneal hematomas.
, D. Apply a tight, rigid ice pack directly onto the fundal
ridge to induce vasoconstriction.
Correct Answer: B. Instruct the client to empty
their bladder completely, or prepare to perform
an aseptic in-and-out catheterization.
Rationale: A uterine fundus that is boggy, high, and
deviated to the right indicates uterine atony caused by
bladder distention. A full bladder displaces the uterus,
preventing it from contracting properly. Assisting the
client to void or catheterizing them allows the uterus to
contract effectively.
4. A nurse is reviewing laboratory values for a newborn who
is 12 hours old and notes a total serum bilirubin level of 14
mg/dL. The infant is scheduled to begin phototherapy.
Which of the following interventions should the nurse
include in the newborn's plan of care?
A. Apply thick layers of protective zinc oxide ointment
over the newborn's skin to prevent thermal friction burns.
B. Dress the infant in a standard long-sleeve cotton
swaddle blanket to minimize ambient heat energy loss.
C. Cover the newborn's eyes completely with an opaque
safety shield mask and keep them undressed except for a
diaper.
D. Limit the newborn's oral fluid intake to distilled water
exclusively to avoid formula-based protein binds.
Correct Answer: C. Cover the newborn's eyes
completely with an opaque safety shield mask and
keep them undressed except for a diaper.
Rationale: Phototherapy requires maximizing skin
exposure to the therapeutic blue-green light waves to
break down bilirubin. The eyes must be fully protected
with an opaque mask to prevent retinal damage, and skin
assessments must occur regularly. [1, 2]
, 5. A nurse is providing discharge teaching to a client who is
postpartum and has chosen to formula-feed her newborn.
The client reports experiencing severe, painful bilateral
breast engorgement. Which of the following instructions
should the nurse deliver to suppress lactation safely?
A. Massage the breasts under a warm, running shower
stream for twenty minutes twice daily.
B. Use a high-efficiency electric breast pump every two
hours to clear out the milk ducts completely.
C. Wear a snug, supportive sports bra continuously, apply
cold cabbage leaves or ice packs, and avoid breast
stimulation.
D. Express a small amount of colostrum manually onto the
areola area every hour to soothe the skin surface.
Correct Answer: C. Wear a snug, supportive
sports bra continuously, apply cold cabbage leaves
or ice packs, and avoid breast stimulation.
Rationale: For non-nursing mothers, treating
engorgement requires avoiding any form of breast
stimulation or heat, which triggers further prolactin
release. Cold applications, cabbage leaves, and a tight
bra promote vasoconstriction and suppress lactation.
6. A nurse is assessing a pregnant client who is at 32 weeks of
gestation and has been diagnosed with severe
preeclampsia. Which of the following clinical findings
represents a classic sign of worsening disease and central
nervous system irritability?
A. Hypo-reactive deep tendon reflexes recorded at a flat 0
baseline index score.
B. Sudden development of generalized blurred vision, a
persistent frontal headache, and hyper-reflexia with
clonus.
C. A gradual reduction in maternal core body temperature
below ninety-six degrees Fahrenheit.
