TEST BANK
Introduction to Maternity and Pediatric Nursing 10th
Edition Test Bank and Answer Key – Gloria Leifer
Maternal Child Nursing Exam Questions & Solutions
Section 1: Maternity Nursing
1. A pregnant woman reports a severe headache and blurred vision. What condition is suspected?
A. Gestational diabetes
B. Preeclampsia
C. Anemia
D. Hyperemesis gravidarum
Correct answer: B
Rationale: Severe headache and blurred vision are warning signs of severe preeclampsia, which is
characterized by hypertension and proteinuria after 20 weeks of gestation.
2. Which finding is most indicative of true labor?
A. Irregular contractions that stop with rest
B. Contractions felt in the abdomen only
C. Progressive cervical dilation and effacement
D. Pain relieved by hydration
Correct answer: C
Rationale: True labor is characterized by progressive cervical change, unlike false labor which
involves irregular contractions that often stop with rest or hydration.
3. A newborn's Apgar score at 1 minute is 4. What is the priority action?
A. Routine observation
B. Immediate resuscitation measures
C. Encourage breastfeeding
D. Document and reassess at 5 minutes
Correct answer: B
Rationale: A score of 4 indicates moderate distress requiring immediate intervention and
resuscitation.
4. A postpartum client saturates one pad in 15 minutes with large clots and has a boggy uterus.
What is the nurse's priority action?
A. Administer oxytocin
B. Massage the fundus
C. Notify provider
D. Place client in Trendelenburg
Correct answer: B
Rationale: Heavy bleeding with a boggy uterus indicates uterine atony. Fundal massage is the first-
line intervention to stimulate uterine contraction and control hemorrhage.
5. A newborn is born with meconium-stained amniotic fluid. What is the first action?
A. Stimulate the newborn
B. Suction the airway immediately
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C. Start feeding
D. Dry and wrap the infant
Correct answer: B
Rationale: Suctioning the airway is the priority to prevent meconium aspiration syndrome.
6. What is the most appropriate position for a pregnant woman in labor?
A. Supine position
B. Prone position
C. Left lateral position
D. Head-down position
Correct answer: C
Rationale: The left lateral position improves uteroplacental circulation and prevents supine
hypotension syndrome.
7. A pregnant client at 34 weeks gestation reports sudden severe abdominal pain, vaginal
bleeding, and a rigid abdomen. The fetal heart rate is 90 bpm. What is the priority action?
A. Place the client in supine position
B. Prepare for immediate delivery
C. Start IV fluids and oxygen
D. Encourage ambulation
Correct answer: C
Rationale: Findings suggest placental abruption with fetal distress. Priority is maternal stabilization
with oxygen and IV fluids.
8. A client at 28 weeks gestation reports painless bright red vaginal bleeding. What condition is
suspected?
A. Placenta previa
B. Ectopic pregnancy
C. Uterine rupture
D. Preterm labor
Correct answer: A
Rationale: Painless bright red vaginal bleeding in the third trimester is the classic symptom of
placenta previa.
9. A pregnant client at 34 weeks gestation is diagnosed with preeclampsia. Which findings require
immediate intervention? (Select all that apply)
A. Blood pressure 168/112 mmHg
B. 2+ protein in urine
C. Severe headache
D. Blurred vision
E. Mild ankle swelling
Correct answers: A, C, D
Rationale: Severe hypertension (A) and neurologic symptoms (C, D) indicate worsening preeclampsia
and require immediate intervention. Mild edema (E) is expected in pregnancy.
10. A laboring client is fully dilated and feels the urge to push. What stage of labor is this?
A. First stage
B. Second stage
C. Third stage
D. Fourth stage
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Correct answer: B
Rationale: The second stage of labor begins with full cervical dilation (10 cm) and ends with the birth
of the infant. The urge to push is characteristic of this stage.
11. A nurse is preparing a laboring client for an amniotomy. Immediately after the procedure,
what is most important for the nurse to assess?
A. Contraction strength
B. Maternal temperature
C. Fetal heart rate (FHR)
D. Maternal blood pressure
Correct answer: C
Rationale: The FHR should be assessed before and after amniotomy to detect changes that may
indicate cord compression or prolapse.
12. A newborn is noted to have a temperature of 96.5°F (35.8°C). What is the nurse's priority
intervention?
A. Give formula feeding
B. Place under radiant warmer
C. Notify provider immediately
D. Bathe the newborn
Correct answer: B
Rationale: Hypothermia in newborns requires immediate warming to prevent complications such as
hypoglycemia and respiratory distress. Placing under a radiant warmer is the priority action.
13. What is the normal birth weight of a full-term newborn?
A. 1.5–2.0 kg
B. 2.5–4.0 kg
C. 4.5–5.5 kg
D. 5.5–6.5 kg
Correct answer: B
Rationale: Normal full-term birth weight ranges from 2.5 to 4.0 kg (approximately 5.5 to 8.8 lbs).
14. Which finding indicates preeclampsia?
A. Proteinuria and hypertension
B. Hypoglycemia
C. Bradycardia
D. Low body temperature
Correct answer: A
Rationale: Preeclampsia is defined by the presence of hypertension and proteinuria after 20 weeks
of gestation.
15. A breastfeeding postpartum client is diagnosed with mastitis. Which statement indicates she
understands the teaching?
A. "Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my period."
B. "I will pump my breasts and discard the milk until the infection is gone."
C. "I can start smoking cigarettes while breastfeeding because it will not affect my baby."
D. "When I take a warm shower after I breastfeed, it relieves the pain from being engorged."
Correct answer: A
Rationale: Continuous breastfeeding on a 3- to 4-hour schedule during the day causes a release of
prolactin, which can suppress ovulation and menses. However, this is not completely effective as
, TEST BANK
birth control. Options B, C, and D are incorrect as alcohol, nicotine, and heat can negatively affect
breastfeeding.
16. A postpartum client has a boggy uterus and heavy bleeding. What is the priority nursing
action?
A. Apply ice packs
B. Perform fundal massage
C. Encourage ambulation
D. Administer antibiotics
Correct answer: B
Rationale: A boggy uterus suggests uterine atony; fundal massage helps stimulate uterine
contraction and control hemorrhage.
17. A nurse is caring for a pregnant client in the first trimester. Which statement by the client
indicates understanding of nutrition teaching?
A. "I should increase my caffeine intake for energy."
B. "I need extra folic acid to prevent birth defects."
C. "I should avoid all fruits during pregnancy."
D. "I should restrict all carbohydrates."
Correct answer: B
Rationale: Folic acid is essential during the first trimester to prevent neural tube defects in the
developing fetus.
18. An expectant father tells the nurse he fears his wife is "losing her mind" because she talks to
the baby and reprimands it when it moves too much. What should the nurse do?
A. Suggest his wife seek professional counseling
B. Recommend he ignore the behavior
C. Advise him to talk to the baby instead
D. Reassure him that normal maternal-fetal bonding is occurring
Correct answer: D
Rationale: These behaviors are positive signs of maternal-fetal bonding and do not reflect
ambivalence or mental health issues.
19. Which vaccine is given at birth in many countries?
A. DPT
B. BCG
C. Measles
D. HPV
Correct answer: B
Rationale: The BCG (Bacillus Calmette-Guérin) vaccine is administered at birth in many countries to
prevent tuberculosis.
20. A newborn has yellow skin at 18 hours of life. What is the nurse's priority action?
A. Start phototherapy immediately
B. Monitor bilirubin levels
C. Stop feeding
D. Administer antibiotics
Correct answer: B
Rationale: Jaundice in a newborn <24 hours old is considered pathologic and requires further
evaluation by monitoring bilirubin levels. Phototherapy is initiated based on bilirubin levels.
Introduction to Maternity and Pediatric Nursing 10th
Edition Test Bank and Answer Key – Gloria Leifer
Maternal Child Nursing Exam Questions & Solutions
Section 1: Maternity Nursing
1. A pregnant woman reports a severe headache and blurred vision. What condition is suspected?
A. Gestational diabetes
B. Preeclampsia
C. Anemia
D. Hyperemesis gravidarum
Correct answer: B
Rationale: Severe headache and blurred vision are warning signs of severe preeclampsia, which is
characterized by hypertension and proteinuria after 20 weeks of gestation.
2. Which finding is most indicative of true labor?
A. Irregular contractions that stop with rest
B. Contractions felt in the abdomen only
C. Progressive cervical dilation and effacement
D. Pain relieved by hydration
Correct answer: C
Rationale: True labor is characterized by progressive cervical change, unlike false labor which
involves irregular contractions that often stop with rest or hydration.
3. A newborn's Apgar score at 1 minute is 4. What is the priority action?
A. Routine observation
B. Immediate resuscitation measures
C. Encourage breastfeeding
D. Document and reassess at 5 minutes
Correct answer: B
Rationale: A score of 4 indicates moderate distress requiring immediate intervention and
resuscitation.
4. A postpartum client saturates one pad in 15 minutes with large clots and has a boggy uterus.
What is the nurse's priority action?
A. Administer oxytocin
B. Massage the fundus
C. Notify provider
D. Place client in Trendelenburg
Correct answer: B
Rationale: Heavy bleeding with a boggy uterus indicates uterine atony. Fundal massage is the first-
line intervention to stimulate uterine contraction and control hemorrhage.
5. A newborn is born with meconium-stained amniotic fluid. What is the first action?
A. Stimulate the newborn
B. Suction the airway immediately
, TEST BANK
C. Start feeding
D. Dry and wrap the infant
Correct answer: B
Rationale: Suctioning the airway is the priority to prevent meconium aspiration syndrome.
6. What is the most appropriate position for a pregnant woman in labor?
A. Supine position
B. Prone position
C. Left lateral position
D. Head-down position
Correct answer: C
Rationale: The left lateral position improves uteroplacental circulation and prevents supine
hypotension syndrome.
7. A pregnant client at 34 weeks gestation reports sudden severe abdominal pain, vaginal
bleeding, and a rigid abdomen. The fetal heart rate is 90 bpm. What is the priority action?
A. Place the client in supine position
B. Prepare for immediate delivery
C. Start IV fluids and oxygen
D. Encourage ambulation
Correct answer: C
Rationale: Findings suggest placental abruption with fetal distress. Priority is maternal stabilization
with oxygen and IV fluids.
8. A client at 28 weeks gestation reports painless bright red vaginal bleeding. What condition is
suspected?
A. Placenta previa
B. Ectopic pregnancy
C. Uterine rupture
D. Preterm labor
Correct answer: A
Rationale: Painless bright red vaginal bleeding in the third trimester is the classic symptom of
placenta previa.
9. A pregnant client at 34 weeks gestation is diagnosed with preeclampsia. Which findings require
immediate intervention? (Select all that apply)
A. Blood pressure 168/112 mmHg
B. 2+ protein in urine
C. Severe headache
D. Blurred vision
E. Mild ankle swelling
Correct answers: A, C, D
Rationale: Severe hypertension (A) and neurologic symptoms (C, D) indicate worsening preeclampsia
and require immediate intervention. Mild edema (E) is expected in pregnancy.
10. A laboring client is fully dilated and feels the urge to push. What stage of labor is this?
A. First stage
B. Second stage
C. Third stage
D. Fourth stage
, TEST BANK
Correct answer: B
Rationale: The second stage of labor begins with full cervical dilation (10 cm) and ends with the birth
of the infant. The urge to push is characteristic of this stage.
11. A nurse is preparing a laboring client for an amniotomy. Immediately after the procedure,
what is most important for the nurse to assess?
A. Contraction strength
B. Maternal temperature
C. Fetal heart rate (FHR)
D. Maternal blood pressure
Correct answer: C
Rationale: The FHR should be assessed before and after amniotomy to detect changes that may
indicate cord compression or prolapse.
12. A newborn is noted to have a temperature of 96.5°F (35.8°C). What is the nurse's priority
intervention?
A. Give formula feeding
B. Place under radiant warmer
C. Notify provider immediately
D. Bathe the newborn
Correct answer: B
Rationale: Hypothermia in newborns requires immediate warming to prevent complications such as
hypoglycemia and respiratory distress. Placing under a radiant warmer is the priority action.
13. What is the normal birth weight of a full-term newborn?
A. 1.5–2.0 kg
B. 2.5–4.0 kg
C. 4.5–5.5 kg
D. 5.5–6.5 kg
Correct answer: B
Rationale: Normal full-term birth weight ranges from 2.5 to 4.0 kg (approximately 5.5 to 8.8 lbs).
14. Which finding indicates preeclampsia?
A. Proteinuria and hypertension
B. Hypoglycemia
C. Bradycardia
D. Low body temperature
Correct answer: A
Rationale: Preeclampsia is defined by the presence of hypertension and proteinuria after 20 weeks
of gestation.
15. A breastfeeding postpartum client is diagnosed with mastitis. Which statement indicates she
understands the teaching?
A. "Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my period."
B. "I will pump my breasts and discard the milk until the infection is gone."
C. "I can start smoking cigarettes while breastfeeding because it will not affect my baby."
D. "When I take a warm shower after I breastfeed, it relieves the pain from being engorged."
Correct answer: A
Rationale: Continuous breastfeeding on a 3- to 4-hour schedule during the day causes a release of
prolactin, which can suppress ovulation and menses. However, this is not completely effective as
, TEST BANK
birth control. Options B, C, and D are incorrect as alcohol, nicotine, and heat can negatively affect
breastfeeding.
16. A postpartum client has a boggy uterus and heavy bleeding. What is the priority nursing
action?
A. Apply ice packs
B. Perform fundal massage
C. Encourage ambulation
D. Administer antibiotics
Correct answer: B
Rationale: A boggy uterus suggests uterine atony; fundal massage helps stimulate uterine
contraction and control hemorrhage.
17. A nurse is caring for a pregnant client in the first trimester. Which statement by the client
indicates understanding of nutrition teaching?
A. "I should increase my caffeine intake for energy."
B. "I need extra folic acid to prevent birth defects."
C. "I should avoid all fruits during pregnancy."
D. "I should restrict all carbohydrates."
Correct answer: B
Rationale: Folic acid is essential during the first trimester to prevent neural tube defects in the
developing fetus.
18. An expectant father tells the nurse he fears his wife is "losing her mind" because she talks to
the baby and reprimands it when it moves too much. What should the nurse do?
A. Suggest his wife seek professional counseling
B. Recommend he ignore the behavior
C. Advise him to talk to the baby instead
D. Reassure him that normal maternal-fetal bonding is occurring
Correct answer: D
Rationale: These behaviors are positive signs of maternal-fetal bonding and do not reflect
ambivalence or mental health issues.
19. Which vaccine is given at birth in many countries?
A. DPT
B. BCG
C. Measles
D. HPV
Correct answer: B
Rationale: The BCG (Bacillus Calmette-Guérin) vaccine is administered at birth in many countries to
prevent tuberculosis.
20. A newborn has yellow skin at 18 hours of life. What is the nurse's priority action?
A. Start phototherapy immediately
B. Monitor bilirubin levels
C. Stop feeding
D. Administer antibiotics
Correct answer: B
Rationale: Jaundice in a newborn <24 hours old is considered pathologic and requires further
evaluation by monitoring bilirubin levels. Phototherapy is initiated based on bilirubin levels.
