1. A nurse is caring for a pregnant client at 28 weeks gestation who has been
diagnosed with gestational diabetes mellitus (GDM). Which of the following
interventions is the priority when planning care for this client?
A. Encourage the client to perform daily fetal kick counts.
B. Teach the client how to monitor her blood glucose levels.
C. Provide education on the importance of an appropriate prenatal vitamin regimen.
D. Assess the client's blood pressure regularly for signs of preeclampsia.
Answer: B. Teach the client how to monitor her blood glucose levels.
Rationale: The priority for a client with GDM is to ensure proper blood glucose management to
prevent complications for both the mother and fetus. Regular blood glucose monitoring is critical
in managing the condition effectively.
2. A nurse is caring for a postpartum client who had a cesarean section delivery.
The client reports feeling lightheaded and faint. Which of the following actions
should the nurse take first?
A. Increase the client's fluid intake.
B. Take the client's blood pressure.
C. Administer pain medication.
D. Elevate the head of the bed.
Answer: B. Take the client's blood pressure.
Rationale: Lightheadedness and fainting may indicate hypotension, which can be assessed by
measuring blood pressure. This is the first step to determine if the client’s symptoms are related
to a drop in blood pressure.
3. A nurse is performing a physical assessment on a newborn and observes the
presence of a small, soft bulge on the infant's abdomen. The nurse suspects a
congenital umbilical hernia. Which of the following is the most appropriate
action for the nurse to take?
A. Document the finding and reassess at the next visit.
B. Notify the provider immediately for surgical intervention.
C. Apply pressure to the bulge to reduce it.
D. Perform a complete neurological assessment.
Answer: A. Document the finding and reassess at the next visit.
Rationale: Umbilical hernias are common in newborns and usually resolve spontaneously within
, the first year of life. Documentation and follow-up are appropriate, unless the hernia is large or
shows signs of complications.
4. A nurse is caring for a 34-week gestation pregnant client who presents with
severe headache, visual disturbances, and elevated blood pressure. Which of the
following complications should the nurse suspect?
A. Placenta previa
B. Preeclampsia
C. Gestational diabetes
D. Preterm labor
Answer: B. Preeclampsia
Rationale: Preeclampsia is characterized by hypertension, headaches, and visual disturbances,
along with proteinuria. These symptoms are classic indicators of the condition, which requires
prompt management.
5. A postpartum client is being discharged after a vaginal delivery. The nurse
provides instructions on self-care and warns the client about which of the
following signs of complications?
A. Increased vaginal bleeding with clots.
B. Painful urination with burning.
C. Persistent fever and chills.
D. Decreased uterine contractions after breastfeeding.
Answer: C. Persistent fever and chills.
Rationale: Persistent fever and chills can indicate an infection, such as endometritis or a urinary
tract infection, and should be reported to the healthcare provider immediately.
6. A nurse is providing discharge teaching to a new mother who is breastfeeding.
Which of the following statements by the mother indicates an understanding of
the teaching?
A. “I will only breastfeed once every four hours.”
B. “I should wait until my baby cries to offer the breast.”
C. “I should nurse my baby for at least 15 minutes on each breast.”
D. “I need to alternate sides when breastfeeding to avoid engorgement.”
diagnosed with gestational diabetes mellitus (GDM). Which of the following
interventions is the priority when planning care for this client?
A. Encourage the client to perform daily fetal kick counts.
B. Teach the client how to monitor her blood glucose levels.
C. Provide education on the importance of an appropriate prenatal vitamin regimen.
D. Assess the client's blood pressure regularly for signs of preeclampsia.
Answer: B. Teach the client how to monitor her blood glucose levels.
Rationale: The priority for a client with GDM is to ensure proper blood glucose management to
prevent complications for both the mother and fetus. Regular blood glucose monitoring is critical
in managing the condition effectively.
2. A nurse is caring for a postpartum client who had a cesarean section delivery.
The client reports feeling lightheaded and faint. Which of the following actions
should the nurse take first?
A. Increase the client's fluid intake.
B. Take the client's blood pressure.
C. Administer pain medication.
D. Elevate the head of the bed.
Answer: B. Take the client's blood pressure.
Rationale: Lightheadedness and fainting may indicate hypotension, which can be assessed by
measuring blood pressure. This is the first step to determine if the client’s symptoms are related
to a drop in blood pressure.
3. A nurse is performing a physical assessment on a newborn and observes the
presence of a small, soft bulge on the infant's abdomen. The nurse suspects a
congenital umbilical hernia. Which of the following is the most appropriate
action for the nurse to take?
A. Document the finding and reassess at the next visit.
B. Notify the provider immediately for surgical intervention.
C. Apply pressure to the bulge to reduce it.
D. Perform a complete neurological assessment.
Answer: A. Document the finding and reassess at the next visit.
Rationale: Umbilical hernias are common in newborns and usually resolve spontaneously within
, the first year of life. Documentation and follow-up are appropriate, unless the hernia is large or
shows signs of complications.
4. A nurse is caring for a 34-week gestation pregnant client who presents with
severe headache, visual disturbances, and elevated blood pressure. Which of the
following complications should the nurse suspect?
A. Placenta previa
B. Preeclampsia
C. Gestational diabetes
D. Preterm labor
Answer: B. Preeclampsia
Rationale: Preeclampsia is characterized by hypertension, headaches, and visual disturbances,
along with proteinuria. These symptoms are classic indicators of the condition, which requires
prompt management.
5. A postpartum client is being discharged after a vaginal delivery. The nurse
provides instructions on self-care and warns the client about which of the
following signs of complications?
A. Increased vaginal bleeding with clots.
B. Painful urination with burning.
C. Persistent fever and chills.
D. Decreased uterine contractions after breastfeeding.
Answer: C. Persistent fever and chills.
Rationale: Persistent fever and chills can indicate an infection, such as endometritis or a urinary
tract infection, and should be reported to the healthcare provider immediately.
6. A nurse is providing discharge teaching to a new mother who is breastfeeding.
Which of the following statements by the mother indicates an understanding of
the teaching?
A. “I will only breastfeed once every four hours.”
B. “I should wait until my baby cries to offer the breast.”
C. “I should nurse my baby for at least 15 minutes on each breast.”
D. “I need to alternate sides when breastfeeding to avoid engorgement.”
