1. A nurse is caring for a client in the fourth stage of labor. What is the most
important assessment the nurse should perform during this stage?
a) Assess the fetal heart rate
b) Assess the uterine tone
c) Perform a vaginal exam
d) Administer pain relief medication
Answer: b) Assess the uterine tone
Rationale: The fourth stage of labor refers to the first 1-2 hours after birth. It is crucial to assess
uterine tone to prevent excessive bleeding, as the uterus needs to remain contracted to minimize
postpartum hemorrhage.
2. A client is at 32 weeks of gestation and presents with preeclampsia. What is the
priority nursing action?
a) Administer magnesium sulfate as prescribed
b) Monitor vital signs every hour
c) Encourage oral fluid intake
d) Promote ambulation to reduce swelling
Answer: a) Administer magnesium sulfate as prescribed
Rationale: Magnesium sulfate is commonly prescribed to prevent seizures in preeclampsia.
Monitoring for signs of magnesium toxicity and administering it as ordered is a priority.
3. A postpartum client reports feeling lightheaded and faint upon standing. What
is the best action for the nurse to take?
a) Administer oxygen
b) Have the client sit or lie down
c) Measure vital signs immediately
d) Provide a full liquid diet
Answer: b) Have the client sit or lie down
Rationale: The client may be experiencing orthostatic hypotension due to blood volume changes
postpartum. The priority action is to prevent injury by ensuring the client is safe and sitting or
lying down.
,4. A nurse is teaching a pregnant client about the signs and symptoms of preterm
labor. Which of the following should the nurse include in the teaching?
a) Sudden weight gain
b) Increased fetal movement
c) Constant lower abdominal cramping
d) Increased vaginal discharge
Answer: c) Constant lower abdominal cramping
Rationale: Constant lower abdominal cramping is a common symptom of preterm labor. Other
signs include lower back pain, changes in vaginal discharge, and regular contractions before 37
weeks.
5. A nurse is caring for a newborn with jaundice. What is the priority nursing
intervention?
a) Monitor the infant's bilirubin levels
b) Encourage breastfeeding every 2 hours
c) Place the newborn under a bili-light
d) Administer a vitamin K injection
Answer: c) Place the newborn under a bili-light
Rationale: Phototherapy, using a bili-light, is a common treatment for newborn jaundice. It
helps break down excess bilirubin in the skin, which is the cause of jaundice.
6. A client who delivered vaginally 12 hours ago is experiencing heavy bleeding.
The nurse notes that the uterus is boggy and displaced to the right. What action
should the nurse take first?
a) Perform a vaginal exam
b) Administer oxytocin as prescribed
c) Massage the uterus
d) Increase IV fluids
Answer: c) Massage the uterus
Rationale: A boggy uterus suggests uterine atony, which can lead to postpartum hemorrhage.
Massaging the uterus helps it contract and reduce bleeding.
, 7. A nurse is caring for a newborn with respiratory distress syndrome. Which of
the following interventions should the nurse anticipate?
a) Administration of surfactant
b) Monitoring for hyperglycemia
c) Initiation of phototherapy
d) Administration of vitamin K
Answer: a) Administration of surfactant
Rationale: Respiratory distress syndrome is common in premature infants due to lack of
surfactant. Administering surfactant helps reduce surface tension in the lungs and improves
oxygenation.
8. A client in labor has an epidural block. What is the most important nursing
action?
a) Encourage frequent position changes
b) Monitor for signs of hypotension
c) Administer IV fluids as ordered
d) Provide pain management for breakthrough pain
Answer: b) Monitor for signs of hypotension
Rationale: Epidural anesthesia can cause a drop in blood pressure, leading to hypotension. It is
important to monitor vital signs closely, especially after administration of an epidural.
9. A nurse is preparing to discharge a new mother who plans to breastfeed.
Which of the following should the nurse include in the discharge teaching?
a) Feed the baby every 3-4 hours
b) Offer water in addition to breast milk
c) Start with a 5-minute feeding session on each breast
d) Breastfeeding should be stopped if the baby falls asleep
Answer: a) Feed the baby every 3-4 hours
Rationale: Newborns should be fed every 2-3 hours, or on demand, to establish a good
breastfeeding routine. The baby should not be limited to 5-minute sessions per breast or given
water in place of breast milk.
important assessment the nurse should perform during this stage?
a) Assess the fetal heart rate
b) Assess the uterine tone
c) Perform a vaginal exam
d) Administer pain relief medication
Answer: b) Assess the uterine tone
Rationale: The fourth stage of labor refers to the first 1-2 hours after birth. It is crucial to assess
uterine tone to prevent excessive bleeding, as the uterus needs to remain contracted to minimize
postpartum hemorrhage.
2. A client is at 32 weeks of gestation and presents with preeclampsia. What is the
priority nursing action?
a) Administer magnesium sulfate as prescribed
b) Monitor vital signs every hour
c) Encourage oral fluid intake
d) Promote ambulation to reduce swelling
Answer: a) Administer magnesium sulfate as prescribed
Rationale: Magnesium sulfate is commonly prescribed to prevent seizures in preeclampsia.
Monitoring for signs of magnesium toxicity and administering it as ordered is a priority.
3. A postpartum client reports feeling lightheaded and faint upon standing. What
is the best action for the nurse to take?
a) Administer oxygen
b) Have the client sit or lie down
c) Measure vital signs immediately
d) Provide a full liquid diet
Answer: b) Have the client sit or lie down
Rationale: The client may be experiencing orthostatic hypotension due to blood volume changes
postpartum. The priority action is to prevent injury by ensuring the client is safe and sitting or
lying down.
,4. A nurse is teaching a pregnant client about the signs and symptoms of preterm
labor. Which of the following should the nurse include in the teaching?
a) Sudden weight gain
b) Increased fetal movement
c) Constant lower abdominal cramping
d) Increased vaginal discharge
Answer: c) Constant lower abdominal cramping
Rationale: Constant lower abdominal cramping is a common symptom of preterm labor. Other
signs include lower back pain, changes in vaginal discharge, and regular contractions before 37
weeks.
5. A nurse is caring for a newborn with jaundice. What is the priority nursing
intervention?
a) Monitor the infant's bilirubin levels
b) Encourage breastfeeding every 2 hours
c) Place the newborn under a bili-light
d) Administer a vitamin K injection
Answer: c) Place the newborn under a bili-light
Rationale: Phototherapy, using a bili-light, is a common treatment for newborn jaundice. It
helps break down excess bilirubin in the skin, which is the cause of jaundice.
6. A client who delivered vaginally 12 hours ago is experiencing heavy bleeding.
The nurse notes that the uterus is boggy and displaced to the right. What action
should the nurse take first?
a) Perform a vaginal exam
b) Administer oxytocin as prescribed
c) Massage the uterus
d) Increase IV fluids
Answer: c) Massage the uterus
Rationale: A boggy uterus suggests uterine atony, which can lead to postpartum hemorrhage.
Massaging the uterus helps it contract and reduce bleeding.
, 7. A nurse is caring for a newborn with respiratory distress syndrome. Which of
the following interventions should the nurse anticipate?
a) Administration of surfactant
b) Monitoring for hyperglycemia
c) Initiation of phototherapy
d) Administration of vitamin K
Answer: a) Administration of surfactant
Rationale: Respiratory distress syndrome is common in premature infants due to lack of
surfactant. Administering surfactant helps reduce surface tension in the lungs and improves
oxygenation.
8. A client in labor has an epidural block. What is the most important nursing
action?
a) Encourage frequent position changes
b) Monitor for signs of hypotension
c) Administer IV fluids as ordered
d) Provide pain management for breakthrough pain
Answer: b) Monitor for signs of hypotension
Rationale: Epidural anesthesia can cause a drop in blood pressure, leading to hypotension. It is
important to monitor vital signs closely, especially after administration of an epidural.
9. A nurse is preparing to discharge a new mother who plans to breastfeed.
Which of the following should the nurse include in the discharge teaching?
a) Feed the baby every 3-4 hours
b) Offer water in addition to breast milk
c) Start with a 5-minute feeding session on each breast
d) Breastfeeding should be stopped if the baby falls asleep
Answer: a) Feed the baby every 3-4 hours
Rationale: Newborns should be fed every 2-3 hours, or on demand, to establish a good
breastfeeding routine. The baby should not be limited to 5-minute sessions per breast or given
water in place of breast milk.
