Choice Questions with Detailed Explanations
Question 1
A nurse is caring for a client who is at 38 weeks gestation and reports
experiencing contractions every 5 minutes that last 60 seconds. Which
of the following findings should indicate to the nurse that the client is in
active labor?
A) Cervical dilation of 4 cm
B) Cervical dilation of 6 cm
C) Cervical effacement of 50%
D) Fetal station of -2
Correct Answer: B
Explanation: Active labor is characterized by cervical dilation of 6 cm or
greater with regular, painful contractions. Cervical dilation of 4 cm
indicates the latent phase of labor. Cervical effacement of 50% is an
early sign of cervical changes but does not confirm active labor. Fetal
station of -2 indicates the presenting part is still high in the pelvis and
not indicative of active labor.
Question 2
A nurse is assessing a newborn who is 12 hours old. Which of the
following findings should the nurse report to the provider?
A) Respiratory rate of 45 breaths per minute
B) Heart rate of 160 beats per minute
,C) Axillary temperature of 37.2°C (99°F)
D) Grunting respirations
Correct Answer: D
Explanation: Grunting respirations in a newborn indicate respiratory
distress and should be reported immediately. A respiratory rate of 45
breaths per minute is within the normal range of 30-60 breaths per
minute. A heart rate of 160 beats per minute is within normal limits
(120-160). An axillary temperature of 37.2°C is within the normal range
for a newborn.
Question 3
A nurse is providing teaching to a client who is at 12 weeks gestation
and has gestational diabetes. Which of the following statements by the
client indicates an understanding of the teaching?
A) "I will need to take insulin injections throughout my pregnancy."
B) "I should check my blood glucose 1 hour after each meal."
C) "I can stop monitoring my blood glucose once I reach 20 weeks."
D) "I will only need to check my blood glucose in the morning."
Correct Answer: B
Explanation: Clients with gestational diabetes should check blood
glucose levels 1 hour after meals to monitor postprandial glucose levels.
Insulin may or may not be needed depending on glucose control.
Monitoring continues throughout the entire pregnancy. Checking only in
the morning does not provide adequate information about glucose
control throughout the day.
,Question 4
A nurse is caring for a client who is in the transition phase of labor.
Which of the following actions should the nurse take?
A) Encourage the client to push with each contraction
B) Provide frequent encouragement and reassurance
C) Offer the client a full meal to maintain energy
D) Encourage the client to ambulate frequently
Correct Answer: B
Explanation: During transition, the client may feel out of control and
require frequent encouragement and reassurance. Pushing should not
begin until the cervix is fully dilated. Clients in transition should have
only ice chips or small sips of fluids due to nausea. Ambulation may not
be possible or safe during transition.
Question 5
A nurse is assessing a postpartum client who delivered 2 hours ago.
Which of the following findings should indicate to the nurse that the
client is at risk for postpartum hemorrhage?
A) A firm fundus at the umbilicus
B) Moderate lochia rubra
C) A boggy fundus that deviates to the right
D) Pulse rate of 78 beats per minute
Correct Answer: C
Explanation: A boggy fundus that deviates to the right indicates a full
bladder displacing the uterus, which can lead to uterine atony and
, hemorrhage. A firm fundus is a normal finding. Moderate lochia rubra is
expected. A pulse rate of 78 is within normal limits.
Question 6
A nurse is caring for a newborn who is 24 hours old and has jaundice.
Which of the following laboratory values should the nurse report to the
provider?
A) Total bilirubin 12 mg/dL
B) Direct bilirubin 4 mg/dL
C) Indirect bilirubin 8 mg/dL
D) Total bilirubin 10 mg/dL
Correct Answer: B
Explanation: Direct bilirubin of 4 mg/dL in a newborn is concerning and
may indicate pathological jaundice or biliary obstruction. Total bilirubin
levels in newborns can normally reach up to 12-15 mg/dL in the first few
days. Indirect bilirubin levels of 8 mg/dL are within expected range.
Question 7
A nurse is providing education to a client about the use of oxytocin
during labor. Which of the following information should the nurse
include?
A) Oxytocin will be administered intramuscularly
B) Oxytocin will increase the intensity and frequency of contractions
C) Oxytocin will decrease the client's blood pressure
D) Oxytocin will slow down the labor process
Correct Answer: B