BSN Maternal-Newborn Nursing Exam 3 Practice UPDATED
ACTUAL Questions and CORRECT Answers
1. A nurse is assessing a client who is at 34 weeks of gestation and has a
prescription for magnesium sulfate. Which of the following findings should the
nurse identify as a priority to report to the provider?
A. Flushing and sweating
B. Urine output of 20 mL/hr
C. Absent deep tendon reflexes
D. Respiratory rate of 14/min
Answer: C
Rationale: Magnesium sulfate toxicity is a serious concern. Absent deep tendon reflexes
are an early sign of toxicity and require immediate intervention and discontinuation of the
infusion.
2. A client in labor is receiving oxytocin via continuous IV infusion. The nurse
notes that the fetal heart rate (FHR) monitor shows late decelerations. Which of
the following actions should the nurse take first?
A. Increase the IV fluid rate
B. Discontinue the oxytocin infusion
C. Turn the client to a side-lying position
D. Apply oxygen at 10 L/min via face mask
Answer: B
Rationale: The safety of the fetus is paramount. Discontinuing the oxytocin infusion is the
first action to stop uterine contractions and improve placental perfusion.
,3. A nurse is caring for a client who is at 32 weeks of gestation and has a
suspected placenta previa. Which of the following provider orders should the
nurse clarify?
A. Monitor fetal heart rate continuously
B. Obtain a complete blood count
C. Perform a sterile vaginal exam
D. Maintain the client on bed rest
Answer: C
Rationale: Vaginal examinations are contraindicated in clients with placenta previa
because they can cause severe hemorrhage by traumatizing the placenta.
4. Which of the following medications is administered to a newborn within 1 to
2 hours of birth to prevent ophthalmia neonatorum?
A. Erythromycin ophthalmic ointment
B. Hepatitis B vaccine
C. Vitamin K
D. Gentamicin sulfate
Answer: A
Rationale: Erythromycin ointment is legally required in many jurisdictions to prevent
neonatal blindness caused by gonorrhea or chlamydia.
5. A nurse is teaching a client about the use of Rho(D) immune globulin. The
nurse should explain that it is administered to Rh-negative mothers for which of
the following reasons?
A. To stimulate the production of maternal antibodies
B. To treat jaundice in the newborn
C. To prevent the fetus from developing Rh-negative blood
D. To destroy fetal Rh-positive red blood cells in maternal circulation
Answer: D
, Rationale: Rho(D) immune globulin prevents the mother’s immune system from reacting
to the baby’s Rh-positive blood, thereby preventing isoimmunization in future pregnancies.
6. A nurse is assessing a newborn 1 hour after birth. Which of the following
findings should the nurse report to the provider?
A. Nasal flaring
B. Heart rate of 140/min
C. Generalized petechiae
D. Acrocyanosis
Answer: A
Rationale: Nasal flaring, along with grunting and retractions, are clinical signs of
respiratory distress in a newborn and require immediate evaluation.
7. A nurse is assessing a postpartum client. The fundus is noted to be boggy and
displaced to the right. Which of the following actions should the nurse take?
A. Perform fundal massage
B. Assist the client to the bathroom to void
C. Administer oxytocin IM
D. Increase the IV fluid rate
Answer: B
Rationale: A fundus that is displaced to the right is usually caused by a full bladder.
Assisting the client to void should allow the uterus to return to the midline and contract.
8. A nurse is teaching a postpartum client about lochia. Which of the following
statements indicates an understanding of the teaching?
A. The discharge will change from pink to red over the next week.
B. My lochia will be white in color until I stop breastfeeding.
C. It is normal to see large clots in my discharge for 2 weeks.
D. I should expect my lochia to be bright red for the first 3 days.
Answer: D
ACTUAL Questions and CORRECT Answers
1. A nurse is assessing a client who is at 34 weeks of gestation and has a
prescription for magnesium sulfate. Which of the following findings should the
nurse identify as a priority to report to the provider?
A. Flushing and sweating
B. Urine output of 20 mL/hr
C. Absent deep tendon reflexes
D. Respiratory rate of 14/min
Answer: C
Rationale: Magnesium sulfate toxicity is a serious concern. Absent deep tendon reflexes
are an early sign of toxicity and require immediate intervention and discontinuation of the
infusion.
2. A client in labor is receiving oxytocin via continuous IV infusion. The nurse
notes that the fetal heart rate (FHR) monitor shows late decelerations. Which of
the following actions should the nurse take first?
A. Increase the IV fluid rate
B. Discontinue the oxytocin infusion
C. Turn the client to a side-lying position
D. Apply oxygen at 10 L/min via face mask
Answer: B
Rationale: The safety of the fetus is paramount. Discontinuing the oxytocin infusion is the
first action to stop uterine contractions and improve placental perfusion.
,3. A nurse is caring for a client who is at 32 weeks of gestation and has a
suspected placenta previa. Which of the following provider orders should the
nurse clarify?
A. Monitor fetal heart rate continuously
B. Obtain a complete blood count
C. Perform a sterile vaginal exam
D. Maintain the client on bed rest
Answer: C
Rationale: Vaginal examinations are contraindicated in clients with placenta previa
because they can cause severe hemorrhage by traumatizing the placenta.
4. Which of the following medications is administered to a newborn within 1 to
2 hours of birth to prevent ophthalmia neonatorum?
A. Erythromycin ophthalmic ointment
B. Hepatitis B vaccine
C. Vitamin K
D. Gentamicin sulfate
Answer: A
Rationale: Erythromycin ointment is legally required in many jurisdictions to prevent
neonatal blindness caused by gonorrhea or chlamydia.
5. A nurse is teaching a client about the use of Rho(D) immune globulin. The
nurse should explain that it is administered to Rh-negative mothers for which of
the following reasons?
A. To stimulate the production of maternal antibodies
B. To treat jaundice in the newborn
C. To prevent the fetus from developing Rh-negative blood
D. To destroy fetal Rh-positive red blood cells in maternal circulation
Answer: D
, Rationale: Rho(D) immune globulin prevents the mother’s immune system from reacting
to the baby’s Rh-positive blood, thereby preventing isoimmunization in future pregnancies.
6. A nurse is assessing a newborn 1 hour after birth. Which of the following
findings should the nurse report to the provider?
A. Nasal flaring
B. Heart rate of 140/min
C. Generalized petechiae
D. Acrocyanosis
Answer: A
Rationale: Nasal flaring, along with grunting and retractions, are clinical signs of
respiratory distress in a newborn and require immediate evaluation.
7. A nurse is assessing a postpartum client. The fundus is noted to be boggy and
displaced to the right. Which of the following actions should the nurse take?
A. Perform fundal massage
B. Assist the client to the bathroom to void
C. Administer oxytocin IM
D. Increase the IV fluid rate
Answer: B
Rationale: A fundus that is displaced to the right is usually caused by a full bladder.
Assisting the client to void should allow the uterus to return to the midline and contract.
8. A nurse is teaching a postpartum client about lochia. Which of the following
statements indicates an understanding of the teaching?
A. The discharge will change from pink to red over the next week.
B. My lochia will be white in color until I stop breastfeeding.
C. It is normal to see large clots in my discharge for 2 weeks.
D. I should expect my lochia to be bright red for the first 3 days.
Answer: D
