,Q1 APPLY EVIDENCE-BASED NURSING INTERVENTIONS IN MATERNAL-NEWBORN CARE
A client at 28 weeks gestation with preeclampsia without severe features is
receiving magnesium sulfate. Which assessment finding requires immediate
action?
A. Respiratory rate 12 breaths/min CORRECT
B. Deep tendon reflexes 2+
C. Urine output 30 mL/hr
D. Serum magnesium level 6.0 mEq/L
RATIONALE: Respiratory rate 12 is below the threshold (12 or 14 per protocol) and indicates
magnesium toxicity, requiring immediate intervention. DTRs 2+ and urine output 30 mL/hr are
acceptable; Mg level 6.0 is therapeutic (range 4-7).
Q2 APPLY EVIDENCE-BASED NURSING INTERVENTIONS IN MATERNAL-NEWBORN CARE
A nurse is assessing fetal heart rate patterns. Which finding indicates late
decelerations?
A. Onset of deceleration occurs after the peak of the contraction CORRECT
B. Deceleration is coincident with the contraction and returns to baseline after contraction ends
C. Deceleration has a rapid onset and recovery, occurring before the contraction peak
D. Deceleration is variable in shape and unrelated to contraction timing
RATIONALE: Late decelerations are characterized by a gradual onset that begins after the
contraction peak and returns to baseline after the contraction ends, indicating uteroplacental
insufficiency. Option B describes early decelerations, C describes variable, D is variable.
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,Q3 APPLY EVIDENCE-BASED NURSING INTERVENTIONS IN MATERNAL-NEWBORN CARE
A postpartum client is Rh-negative and her newborn is Rh-positive. The Coombs
test on cord blood is positive. Which nursing action is most appropriate?
A. Administer RhIG (RhoGAM) to the client within 72 hours
B. Administer RhIG to the newborn
C. Withhold RhIG because the client is already sensitized CORRECT
D. Repeat the Coombs test in 24 hours
RATIONALE: A positive Coombs test indicates maternal sensitization (anti-Rh antibodies). RhIG
is not indicated in already sensitized clients; it prevents sensitization, not treat it. Administering
RhIG to the newborn is not recommended.
Q4 APPLY EVIDENCE-BASED NURSING INTERVENTIONS IN MATERNAL-NEWBORN CARE
A nurse is caring for a client with premature rupture of membranes at 34 weeks
gestation. Which finding is most concerning?
A. Maternal temperature 38.2°C (100.8°F) CORRECT
B. Fetal heart rate baseline 140 beats/min with moderate variability
C. Amniotic fluid index of 10 cm
D. Maternal white blood cell count 12,000/mm³
RATIONALE: Fever in the setting of PROM suggests chorioamnionitis, a serious infection
requiring immediate delivery. The other findings are normal or borderline; WBC 12,000 can be
normal in pregnancy, but fever is more specific.
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, Q5 APPLY EVIDENCE-BASED NURSING INTERVENTIONS IN MATERNAL-NEWBORN CARE
A newborn is exhibiting signs of neonatal abstinence syndrome. Which
assessment tool is most appropriate to evaluate the severity?
A. Finnegan Neonatal Abstinence Scoring System CORRECT
B. Apgar score
C. Ballard score
D. NIPS (Neonatal Infant Pain Scale)
RATIONALE: The Finnegan tool is specifically designed to assess neonatal abstinence
syndrome. Apgar assesses cardiopulmonary adaptation, Ballard assesses gestational age, and
NIPS assesses pain, not withdrawal.
Q6 APPLY EVIDENCE-BASED NURSING INTERVENTIONS IN MATERNAL-NEWBORN CARE
A nurse is providing education to a client with gestational diabetes. Which
statement indicates the need for further teaching?
A. I will check my blood sugar before each meal and at bedtime.
B. I can eat any food as long as I take my insulin. CORRECT
C. I should avoid exercising if my blood sugar is above 250 mg/dL.
D. I will report any signs of infection to my provider.
RATIONALE: Clients with gestational diabetes must adhere to a consistent
carbohydrate-controlled meal plan; insulin does not give license to eat unrestricted. The other
statements are correct: monitoring, avoiding exercise with high glucose, and reporting infections.
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A client at 28 weeks gestation with preeclampsia without severe features is
receiving magnesium sulfate. Which assessment finding requires immediate
action?
A. Respiratory rate 12 breaths/min CORRECT
B. Deep tendon reflexes 2+
C. Urine output 30 mL/hr
D. Serum magnesium level 6.0 mEq/L
RATIONALE: Respiratory rate 12 is below the threshold (12 or 14 per protocol) and indicates
magnesium toxicity, requiring immediate intervention. DTRs 2+ and urine output 30 mL/hr are
acceptable; Mg level 6.0 is therapeutic (range 4-7).
Q2 APPLY EVIDENCE-BASED NURSING INTERVENTIONS IN MATERNAL-NEWBORN CARE
A nurse is assessing fetal heart rate patterns. Which finding indicates late
decelerations?
A. Onset of deceleration occurs after the peak of the contraction CORRECT
B. Deceleration is coincident with the contraction and returns to baseline after contraction ends
C. Deceleration has a rapid onset and recovery, occurring before the contraction peak
D. Deceleration is variable in shape and unrelated to contraction timing
RATIONALE: Late decelerations are characterized by a gradual onset that begins after the
contraction peak and returns to baseline after the contraction ends, indicating uteroplacental
insufficiency. Option B describes early decelerations, C describes variable, D is variable.
Page 2
,Q3 APPLY EVIDENCE-BASED NURSING INTERVENTIONS IN MATERNAL-NEWBORN CARE
A postpartum client is Rh-negative and her newborn is Rh-positive. The Coombs
test on cord blood is positive. Which nursing action is most appropriate?
A. Administer RhIG (RhoGAM) to the client within 72 hours
B. Administer RhIG to the newborn
C. Withhold RhIG because the client is already sensitized CORRECT
D. Repeat the Coombs test in 24 hours
RATIONALE: A positive Coombs test indicates maternal sensitization (anti-Rh antibodies). RhIG
is not indicated in already sensitized clients; it prevents sensitization, not treat it. Administering
RhIG to the newborn is not recommended.
Q4 APPLY EVIDENCE-BASED NURSING INTERVENTIONS IN MATERNAL-NEWBORN CARE
A nurse is caring for a client with premature rupture of membranes at 34 weeks
gestation. Which finding is most concerning?
A. Maternal temperature 38.2°C (100.8°F) CORRECT
B. Fetal heart rate baseline 140 beats/min with moderate variability
C. Amniotic fluid index of 10 cm
D. Maternal white blood cell count 12,000/mm³
RATIONALE: Fever in the setting of PROM suggests chorioamnionitis, a serious infection
requiring immediate delivery. The other findings are normal or borderline; WBC 12,000 can be
normal in pregnancy, but fever is more specific.
Page 3
, Q5 APPLY EVIDENCE-BASED NURSING INTERVENTIONS IN MATERNAL-NEWBORN CARE
A newborn is exhibiting signs of neonatal abstinence syndrome. Which
assessment tool is most appropriate to evaluate the severity?
A. Finnegan Neonatal Abstinence Scoring System CORRECT
B. Apgar score
C. Ballard score
D. NIPS (Neonatal Infant Pain Scale)
RATIONALE: The Finnegan tool is specifically designed to assess neonatal abstinence
syndrome. Apgar assesses cardiopulmonary adaptation, Ballard assesses gestational age, and
NIPS assesses pain, not withdrawal.
Q6 APPLY EVIDENCE-BASED NURSING INTERVENTIONS IN MATERNAL-NEWBORN CARE
A nurse is providing education to a client with gestational diabetes. Which
statement indicates the need for further teaching?
A. I will check my blood sugar before each meal and at bedtime.
B. I can eat any food as long as I take my insulin. CORRECT
C. I should avoid exercising if my blood sugar is above 250 mg/dL.
D. I will report any signs of infection to my provider.
RATIONALE: Clients with gestational diabetes must adhere to a consistent
carbohydrate-controlled meal plan; insulin does not give license to eat unrestricted. The other
statements are correct: monitoring, avoiding exercise with high glucose, and reporting infections.
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