NURS240 Maternal-Newborn Nursing –
Comprehensive Study Guide, Original Practice
Questions & Answers, NURS 240 Exam Prep,
Practice Exam, Maternal & Newborn Nursing
Review, Pregnancy & Prenatal Care, Antepartum
Complications, Fetal Development, Labor &
Delivery, Intrapartum Nursing, Postpartum Care,
Newborn Assessment, Breastfeeding, High-Risk
Pregnancy, Maternal-Newborn Nursing Test Bank
Question 1: A nurse is caring for a client at 38 weeks gestation who reports a
sudden onset of severe, sharp abdominal pain accompanied by vaginal
bleeding. The client's uterus is firm and tender to palpation. Which of the
following actions should the nurse take first?
A. Administer oxygen via face mask at 8-10 L/min
B. Insert a large-bore IV catheter
C. Assess fetal heart rate
D. Notify the healthcare provider
CORRECT ANSWER: C. Assess fetal heart rate
Rationale: The client's symptoms are indicative of placental abruption. While all actions
are important, the immediate priority is to assess fetal well-being and obtain a baseline
fetal heart rate to determine the severity of the situation and guide subsequent
interventions.
Question 2: A postpartum client who is Rh-negative and has an Rh-positive
newborn is scheduled to receive Rh(D) immune globulin. The nurse
understands that this medication is administered to prevent which of the
following?
A. Hemolytic disease of the fetus and newborn in subsequent pregnancies
B. Maternal autoimmune hemolytic anemia
C. Neonatal jaundice in the current newborn
D. Fetal thrombocytopenia
CORRECT ANSWER: A. Hemolytic disease of the fetus and newborn in
subsequent pregnancies
Rationale: Rh(D) immune globulin is given to an Rh-negative mother to prevent maternal
sensitization to Rh-positive fetal blood. This prevents the mother from developing
antibodies that could cross the placenta in future pregnancies and cause hemolytic
disease of the fetus and newborn.
Question 3: A nurse is assessing a newborn who is 12 hours old. Which of the
following findings should the nurse report to the healthcare provider?
,A. Heart rate of 140 beats per minute
B. Respiratory rate of 48 breaths per minute
C. Axillary temperature of 36.6°C (97.9°F)
D. Grunting respirations
CORRECT ANSWER: D. Grunting respirations
Rationale: Grunting is a sign of respiratory distress in a newborn and can indicate
conditions such as respiratory distress syndrome, transient tachypnea of the newborn,
or infection. The other options are within normal limits for a newborn.
Question 4: A client at 32 weeks gestation is diagnosed with gestational
diabetes mellitus. The nurse should instruct the client to monitor for which of
the following complications?
A. Post-term delivery
B. Macrosomia
C. Neonatal hyperglycemia
D. Maternal hypotension
CORRECT ANSWER: B. Macrosomia
Rationale: Gestational diabetes mellitus can cause fetal hyperinsulinemia, leading to
excessive fetal growth (macrosomia). This can result in shoulder dystocia and birth
injuries during delivery.
Question 5: A nurse is providing teaching to a client about non-stress testing.
Which of the following statements by the client indicates a need for further
teaching?
A. "I need to have a full bladder for this test."
B. "The test will take about 20-40 minutes."
C. "The test monitors my baby's heart rate in response to movement."
D. "I will have a belt placed around my abdomen."
CORRECT ANSWER: A. "I need to have a full bladder for this test."
Rationale: A full bladder is not required for a non-stress test. In fact, an empty bladder is
often preferred for maternal comfort. A full bladder is typically needed for a biophysical
profile or early ultrasound.
Question 6: A client in active labor is receiving an epidural analgesia. Which of
the following nursing interventions should be included in the plan of care?
A. Maintain the client in a supine position
B. Assess the client's blood pressure every 5-10 minutes
C. Encourage the client to ambulate
D. Monitor for tachycardia as an adverse effect
CORRECT ANSWER: B. Assess the client's blood pressure every 5-10 minutes
,Rationale: Epidural analgesia can cause sympathetic blockade, leading to maternal
hypotension. Frequent blood pressure monitoring is essential to detect and treat
hypotension promptly to maintain uteroplacental perfusion.
Question 7: A nurse is caring for a newborn with a bilirubin level of 18 mg/dL.
The healthcare provider prescribes phototherapy. Which of the following
nursing actions is appropriate?
A. Apply lotion to the newborn's skin before phototherapy
B. Position the newborn prone for the duration of the therapy
C. Cover the newborn's eyes with opaque shields
D. Discontinue phototherapy during feeding times
CORRECT ANSWER: C. Cover the newborn's eyes with opaque shields
Rationale: During phototherapy, the newborn's eyes must be covered with opaque
shields to prevent retinal damage from the intense light. The shields should be removed
during feeding and care times to allow for visual stimulation.
Question 8: A client who is 24 hours postpartum is experiencing severe
perineal pain and a feeling of pressure. The nurse notes a bluish, bulging mass
at the introitus. Which of the following conditions is the client most likely
experiencing?
A. Uterine inversion
B. Perineal hematoma
C. Cystocele
D. Uterine atony
CORRECT ANSWER: B. Perineal hematoma
Rationale: The presence of a bluish, bulging mass at the introitus with severe pain and
pressure is characteristic of a perineal hematoma. This can result from trauma during
delivery and requires prompt medical attention.
Question 9: A nurse is performing a vaginal exam on a client in labor. The
cervix is 8 cm dilated, 90% effaced, and the presenting part is at 0 station. The
client is in which phase of the first stage of labor?
A. Latent phase
B. Active phase
C. Transition phase
D. Descent phase
CORRECT ANSWER: C. Transition phase
Rationale: The transition phase of the first stage of labor is characterized by cervical
dilation from 7 to 10 cm, complete effacement, and fetal descent to 0 to +1 station. The
active phase is 4 to 7 cm, and the latent phase is 0 to 3 cm.
, Question 10: A nurse is providing education about breastfeeding to a new
mother. Which of the following positions is most effective for a client who had
a cesarean birth?
A. Cradle hold
B. Cross-cradle hold
C. Football hold
D. Side-lying position
CORRECT ANSWER: C. Football hold
Rationale: The football hold is most effective for clients who have had a cesarean birth
because it keeps the infant's weight off the abdominal incision, reducing pain and
pressure while allowing for effective breastfeeding.
Question 11: A client at 34 weeks gestation with preeclampsia is receiving
magnesium sulfate. The nurse should assess for which of the following signs of
magnesium toxicity?
A. Increased deep tendon reflexes
B. Respiratory rate of 18 breaths per minute
C. Urinary output of 40 mL/hr
D. Absent deep tendon reflexes
CORRECT ANSWER: D. Absent deep tendon reflexes
Rationale: Signs of magnesium toxicity include loss of deep tendon reflexes (areflexia),
respiratory depression, and oliguria. The therapeutic range for magnesium sulfate
requires careful monitoring to prevent toxicity.
Question 12: A nurse is assessing a newborn's Apgar score at 1 minute of life.
The newborn has a heart rate of 120 bpm, a strong cry, some flexion of the
extremities, a pink body with blue extremities, and is actively moving. What
Apgar score should the nurse assign?
A. 7
B. 8
C. 9
D. 10
CORRECT ANSWER: B. 8
Rationale: The newborn receives 2 points for heart rate (>100 bpm), 2 points for
respiratory effort (strong cry), 1 point for muscle tone (some flexion), 1 point for color
(pink body, blue extremities), and 2 points for reflex irritability (active movement). Total
= 8.
Question 13: A client in labor is exhibiting late decelerations on the fetal heart
rate tracing. Which of the following actions should the nurse take first?
Comprehensive Study Guide, Original Practice
Questions & Answers, NURS 240 Exam Prep,
Practice Exam, Maternal & Newborn Nursing
Review, Pregnancy & Prenatal Care, Antepartum
Complications, Fetal Development, Labor &
Delivery, Intrapartum Nursing, Postpartum Care,
Newborn Assessment, Breastfeeding, High-Risk
Pregnancy, Maternal-Newborn Nursing Test Bank
Question 1: A nurse is caring for a client at 38 weeks gestation who reports a
sudden onset of severe, sharp abdominal pain accompanied by vaginal
bleeding. The client's uterus is firm and tender to palpation. Which of the
following actions should the nurse take first?
A. Administer oxygen via face mask at 8-10 L/min
B. Insert a large-bore IV catheter
C. Assess fetal heart rate
D. Notify the healthcare provider
CORRECT ANSWER: C. Assess fetal heart rate
Rationale: The client's symptoms are indicative of placental abruption. While all actions
are important, the immediate priority is to assess fetal well-being and obtain a baseline
fetal heart rate to determine the severity of the situation and guide subsequent
interventions.
Question 2: A postpartum client who is Rh-negative and has an Rh-positive
newborn is scheduled to receive Rh(D) immune globulin. The nurse
understands that this medication is administered to prevent which of the
following?
A. Hemolytic disease of the fetus and newborn in subsequent pregnancies
B. Maternal autoimmune hemolytic anemia
C. Neonatal jaundice in the current newborn
D. Fetal thrombocytopenia
CORRECT ANSWER: A. Hemolytic disease of the fetus and newborn in
subsequent pregnancies
Rationale: Rh(D) immune globulin is given to an Rh-negative mother to prevent maternal
sensitization to Rh-positive fetal blood. This prevents the mother from developing
antibodies that could cross the placenta in future pregnancies and cause hemolytic
disease of the fetus and newborn.
Question 3: A nurse is assessing a newborn who is 12 hours old. Which of the
following findings should the nurse report to the healthcare provider?
,A. Heart rate of 140 beats per minute
B. Respiratory rate of 48 breaths per minute
C. Axillary temperature of 36.6°C (97.9°F)
D. Grunting respirations
CORRECT ANSWER: D. Grunting respirations
Rationale: Grunting is a sign of respiratory distress in a newborn and can indicate
conditions such as respiratory distress syndrome, transient tachypnea of the newborn,
or infection. The other options are within normal limits for a newborn.
Question 4: A client at 32 weeks gestation is diagnosed with gestational
diabetes mellitus. The nurse should instruct the client to monitor for which of
the following complications?
A. Post-term delivery
B. Macrosomia
C. Neonatal hyperglycemia
D. Maternal hypotension
CORRECT ANSWER: B. Macrosomia
Rationale: Gestational diabetes mellitus can cause fetal hyperinsulinemia, leading to
excessive fetal growth (macrosomia). This can result in shoulder dystocia and birth
injuries during delivery.
Question 5: A nurse is providing teaching to a client about non-stress testing.
Which of the following statements by the client indicates a need for further
teaching?
A. "I need to have a full bladder for this test."
B. "The test will take about 20-40 minutes."
C. "The test monitors my baby's heart rate in response to movement."
D. "I will have a belt placed around my abdomen."
CORRECT ANSWER: A. "I need to have a full bladder for this test."
Rationale: A full bladder is not required for a non-stress test. In fact, an empty bladder is
often preferred for maternal comfort. A full bladder is typically needed for a biophysical
profile or early ultrasound.
Question 6: A client in active labor is receiving an epidural analgesia. Which of
the following nursing interventions should be included in the plan of care?
A. Maintain the client in a supine position
B. Assess the client's blood pressure every 5-10 minutes
C. Encourage the client to ambulate
D. Monitor for tachycardia as an adverse effect
CORRECT ANSWER: B. Assess the client's blood pressure every 5-10 minutes
,Rationale: Epidural analgesia can cause sympathetic blockade, leading to maternal
hypotension. Frequent blood pressure monitoring is essential to detect and treat
hypotension promptly to maintain uteroplacental perfusion.
Question 7: A nurse is caring for a newborn with a bilirubin level of 18 mg/dL.
The healthcare provider prescribes phototherapy. Which of the following
nursing actions is appropriate?
A. Apply lotion to the newborn's skin before phototherapy
B. Position the newborn prone for the duration of the therapy
C. Cover the newborn's eyes with opaque shields
D. Discontinue phototherapy during feeding times
CORRECT ANSWER: C. Cover the newborn's eyes with opaque shields
Rationale: During phototherapy, the newborn's eyes must be covered with opaque
shields to prevent retinal damage from the intense light. The shields should be removed
during feeding and care times to allow for visual stimulation.
Question 8: A client who is 24 hours postpartum is experiencing severe
perineal pain and a feeling of pressure. The nurse notes a bluish, bulging mass
at the introitus. Which of the following conditions is the client most likely
experiencing?
A. Uterine inversion
B. Perineal hematoma
C. Cystocele
D. Uterine atony
CORRECT ANSWER: B. Perineal hematoma
Rationale: The presence of a bluish, bulging mass at the introitus with severe pain and
pressure is characteristic of a perineal hematoma. This can result from trauma during
delivery and requires prompt medical attention.
Question 9: A nurse is performing a vaginal exam on a client in labor. The
cervix is 8 cm dilated, 90% effaced, and the presenting part is at 0 station. The
client is in which phase of the first stage of labor?
A. Latent phase
B. Active phase
C. Transition phase
D. Descent phase
CORRECT ANSWER: C. Transition phase
Rationale: The transition phase of the first stage of labor is characterized by cervical
dilation from 7 to 10 cm, complete effacement, and fetal descent to 0 to +1 station. The
active phase is 4 to 7 cm, and the latent phase is 0 to 3 cm.
, Question 10: A nurse is providing education about breastfeeding to a new
mother. Which of the following positions is most effective for a client who had
a cesarean birth?
A. Cradle hold
B. Cross-cradle hold
C. Football hold
D. Side-lying position
CORRECT ANSWER: C. Football hold
Rationale: The football hold is most effective for clients who have had a cesarean birth
because it keeps the infant's weight off the abdominal incision, reducing pain and
pressure while allowing for effective breastfeeding.
Question 11: A client at 34 weeks gestation with preeclampsia is receiving
magnesium sulfate. The nurse should assess for which of the following signs of
magnesium toxicity?
A. Increased deep tendon reflexes
B. Respiratory rate of 18 breaths per minute
C. Urinary output of 40 mL/hr
D. Absent deep tendon reflexes
CORRECT ANSWER: D. Absent deep tendon reflexes
Rationale: Signs of magnesium toxicity include loss of deep tendon reflexes (areflexia),
respiratory depression, and oliguria. The therapeutic range for magnesium sulfate
requires careful monitoring to prevent toxicity.
Question 12: A nurse is assessing a newborn's Apgar score at 1 minute of life.
The newborn has a heart rate of 120 bpm, a strong cry, some flexion of the
extremities, a pink body with blue extremities, and is actively moving. What
Apgar score should the nurse assign?
A. 7
B. 8
C. 9
D. 10
CORRECT ANSWER: B. 8
Rationale: The newborn receives 2 points for heart rate (>100 bpm), 2 points for
respiratory effort (strong cry), 1 point for muscle tone (some flexion), 1 point for color
(pink body, blue extremities), and 2 points for reflex irritability (active movement). Total
= 8.
Question 13: A client in labor is exhibiting late decelerations on the fetal heart
rate tracing. Which of the following actions should the nurse take first?
