1. A nurse is providing education to a client who is 8 weeks pregnant about the signs of a
miscarriage. Which of the following symptoms should the nurse instruct the client to report
immediately?
A) Mild cramping
B) Light spotting
C) Severe abdominal pain
D) Breast tenderness
Answer: C) Severe abdominal pain
Rationale: Severe abdominal pain can indicate a miscarriage or other complications, such as an
ectopic pregnancy, and should be reported immediately.
2. A client is 36 weeks pregnant and reports severe swelling of the hands and face. The
nurse should assess for which of the following additional symptoms?
A) Headache and visual disturbances
B) Increased fetal movement
C) Hyperactive reflexes
D) Increased urination
Answer: A) Headache and visual disturbances
Rationale: Severe swelling of the hands and face, along with headache and visual disturbances,
are signs of preeclampsia, which requires immediate assessment.
3. A nurse is teaching a client who is breastfeeding about preventing nipple pain. Which of
the following recommendations should the nurse make?
A) Use a breast pump to express milk before breastfeeding
B) Ensure the baby’s latch is correct
C) Use soap and water to wash the nipples after each feeding
D) Feed the baby for no more than 10 minutes per breast
Answer: B) Ensure the baby’s latch is correct
Rationale: A proper latch helps prevent nipple pain and trauma. Incorrect latching is a common
cause of nipple pain during breastfeeding.
4. A postpartum client has an epidural catheter in place. Which of the following actions
should the nurse take to prevent complications?
,A) Encourage frequent ambulation
B) Monitor for signs of infection at the catheter site
C) Keep the client on strict bed rest
D) Perform active range-of-motion exercises
Answer: B) Monitor for signs of infection at the catheter site
Rationale: It’s important to monitor for infection at the site of the epidural catheter, as infections
can lead to serious complications.
5. The nurse is assessing a newborn after delivery. The newborn’s Apgar score is 4 at 1
minute and 7 at 5 minutes. Which of the following actions should the nurse take first?
A) Administer oxygen via nasal cannula
B) Assess for signs of jaundice
C) Place the newborn on the mother’s chest for skin-to-skin contact
D) Notify the healthcare provider about the score
Answer: A) Administer oxygen via nasal cannula
Rationale: An Apgar score of 4 at 1 minute indicates the need for immediate resuscitation,
including oxygen administration, to support the newborn’s respiratory function.
6. A nurse is caring for a client who is 28 weeks pregnant and has gestational diabetes.
Which of the following should the nurse include in the teaching plan regarding diet?
A) Limit intake of carbohydrates to less than 100g daily
B) Include protein with every meal and snack
C) Avoid all fruits and fruit juices
D) Increase saturated fat intake to manage blood sugar
Answer: B) Include protein with every meal and snack
Rationale: Including protein with meals and snacks helps to stabilize blood sugar levels for
clients with gestational diabetes.
7. A nurse is preparing to administer magnesium sulfate to a client with preeclampsia.
Which of the following actions should the nurse take?
A) Monitor for deep tendon reflexes
B) Encourage the client to ambulate frequently
C) Assess for signs of hypercalcemia
D) Administer magnesium sulfate via intramuscular injection
, Answer: A) Monitor for deep tendon reflexes
Rationale: Magnesium sulfate is a central nervous system depressant and can cause decreased
reflexes, respiratory depression, and other side effects. Monitoring deep tendon reflexes is
essential to detect toxicity.
8. A nurse is providing discharge instructions to a client following a cesarean delivery.
Which of the following instructions should the nurse include?
A) Take a tub bath to promote relaxation and healing
B) Avoid lifting anything heavier than 5 pounds for the first 2 weeks
C) Use a heating pad on the incision site for comfort
D) Resume normal sexual activity within 1 week after delivery
Answer: B) Avoid lifting anything heavier than 5 pounds for the first 2 weeks
Rationale: Clients should avoid heavy lifting after a cesarean delivery to promote healing of the
incision site and prevent complications.
9. A nurse is assessing a postpartum client. The nurse notes that the client’s uterus is
displaced to the right and is not palpable above the symphysis pubis. What is the most
likely cause?
A) Bladder distention
B) Infection
C) Uterine atony
D) Retained placental fragments
Answer: A) Bladder distention
Rationale: A full bladder can displace the uterus to the right and interfere with its involution.
10. The nurse is caring for a newborn who is 1 hour old and has a temperature of 97.0°F
(36.1°C). Which of the following actions should the nurse take?
A) Place the newborn under a radiant warmer
B) Wrap the newborn in a warm blanket and reassess temperature in 30 minutes
C) Offer the newborn a bottle of formula
D) Place the newborn in a warm bath to regulate temperature
Answer: A) Place the newborn under a radiant warmer
Rationale: A newborn with a temperature of 97.0°F (36.1°C) is hypothermic and should be
warmed using a radiant warmer to maintain body temperature.
miscarriage. Which of the following symptoms should the nurse instruct the client to report
immediately?
A) Mild cramping
B) Light spotting
C) Severe abdominal pain
D) Breast tenderness
Answer: C) Severe abdominal pain
Rationale: Severe abdominal pain can indicate a miscarriage or other complications, such as an
ectopic pregnancy, and should be reported immediately.
2. A client is 36 weeks pregnant and reports severe swelling of the hands and face. The
nurse should assess for which of the following additional symptoms?
A) Headache and visual disturbances
B) Increased fetal movement
C) Hyperactive reflexes
D) Increased urination
Answer: A) Headache and visual disturbances
Rationale: Severe swelling of the hands and face, along with headache and visual disturbances,
are signs of preeclampsia, which requires immediate assessment.
3. A nurse is teaching a client who is breastfeeding about preventing nipple pain. Which of
the following recommendations should the nurse make?
A) Use a breast pump to express milk before breastfeeding
B) Ensure the baby’s latch is correct
C) Use soap and water to wash the nipples after each feeding
D) Feed the baby for no more than 10 minutes per breast
Answer: B) Ensure the baby’s latch is correct
Rationale: A proper latch helps prevent nipple pain and trauma. Incorrect latching is a common
cause of nipple pain during breastfeeding.
4. A postpartum client has an epidural catheter in place. Which of the following actions
should the nurse take to prevent complications?
,A) Encourage frequent ambulation
B) Monitor for signs of infection at the catheter site
C) Keep the client on strict bed rest
D) Perform active range-of-motion exercises
Answer: B) Monitor for signs of infection at the catheter site
Rationale: It’s important to monitor for infection at the site of the epidural catheter, as infections
can lead to serious complications.
5. The nurse is assessing a newborn after delivery. The newborn’s Apgar score is 4 at 1
minute and 7 at 5 minutes. Which of the following actions should the nurse take first?
A) Administer oxygen via nasal cannula
B) Assess for signs of jaundice
C) Place the newborn on the mother’s chest for skin-to-skin contact
D) Notify the healthcare provider about the score
Answer: A) Administer oxygen via nasal cannula
Rationale: An Apgar score of 4 at 1 minute indicates the need for immediate resuscitation,
including oxygen administration, to support the newborn’s respiratory function.
6. A nurse is caring for a client who is 28 weeks pregnant and has gestational diabetes.
Which of the following should the nurse include in the teaching plan regarding diet?
A) Limit intake of carbohydrates to less than 100g daily
B) Include protein with every meal and snack
C) Avoid all fruits and fruit juices
D) Increase saturated fat intake to manage blood sugar
Answer: B) Include protein with every meal and snack
Rationale: Including protein with meals and snacks helps to stabilize blood sugar levels for
clients with gestational diabetes.
7. A nurse is preparing to administer magnesium sulfate to a client with preeclampsia.
Which of the following actions should the nurse take?
A) Monitor for deep tendon reflexes
B) Encourage the client to ambulate frequently
C) Assess for signs of hypercalcemia
D) Administer magnesium sulfate via intramuscular injection
, Answer: A) Monitor for deep tendon reflexes
Rationale: Magnesium sulfate is a central nervous system depressant and can cause decreased
reflexes, respiratory depression, and other side effects. Monitoring deep tendon reflexes is
essential to detect toxicity.
8. A nurse is providing discharge instructions to a client following a cesarean delivery.
Which of the following instructions should the nurse include?
A) Take a tub bath to promote relaxation and healing
B) Avoid lifting anything heavier than 5 pounds for the first 2 weeks
C) Use a heating pad on the incision site for comfort
D) Resume normal sexual activity within 1 week after delivery
Answer: B) Avoid lifting anything heavier than 5 pounds for the first 2 weeks
Rationale: Clients should avoid heavy lifting after a cesarean delivery to promote healing of the
incision site and prevent complications.
9. A nurse is assessing a postpartum client. The nurse notes that the client’s uterus is
displaced to the right and is not palpable above the symphysis pubis. What is the most
likely cause?
A) Bladder distention
B) Infection
C) Uterine atony
D) Retained placental fragments
Answer: A) Bladder distention
Rationale: A full bladder can displace the uterus to the right and interfere with its involution.
10. The nurse is caring for a newborn who is 1 hour old and has a temperature of 97.0°F
(36.1°C). Which of the following actions should the nurse take?
A) Place the newborn under a radiant warmer
B) Wrap the newborn in a warm blanket and reassess temperature in 30 minutes
C) Offer the newborn a bottle of formula
D) Place the newborn in a warm bath to regulate temperature
Answer: A) Place the newborn under a radiant warmer
Rationale: A newborn with a temperature of 97.0°F (36.1°C) is hypothermic and should be
warmed using a radiant warmer to maintain body temperature.
