. A 28-year-old pregnant woman in her second trimester presents with a complaint of
heartburn. Which of the following interventions should the nurse recommend to alleviate
this discomfort?
A. Eat large meals to avoid acid reflux.
B. Drink fluids with meals.
C. Sleep in a semi-reclining position.
D. Lie flat after meals.
Answer: C. Sleep in a semi-reclining position.
Rationale: Sleeping in a semi-reclining position helps reduce the risk of acid reflux, which is
common in pregnancy due to hormonal changes and the growing uterus pressing on the stomach.
2. A nurse is caring for a 32-week pregnant woman who is experiencing vaginal bleeding.
Which of the following actions should the nurse take first?
A. Perform a vaginal examination to assess for cervical dilation.
B. Assess the fetal heart rate.
C. Administer oxygen via face mask.
D. Prepare for immediate cesarean delivery.
Answer: B. Assess the fetal heart rate.
Rationale: The first priority is to assess the fetal heart rate to evaluate fetal well-being. Vaginal
bleeding can indicate complications like placenta previa or placental abruption, which require
prompt fetal monitoring.
3. A nurse is educating a pregnant woman about gestational diabetes. Which of the
following statements by the client indicates an understanding of the teaching?
A. “I will need to follow a special diet and check my blood glucose levels regularly.”
B. “I will probably need to take insulin during my pregnancy, but I can stop once the baby is
born.”
C. “Gestational diabetes usually goes away in the second trimester.”
D. “I should eat more high-sugar foods to keep my blood glucose levels stable.”
Answer: A. “I will need to follow a special diet and check my blood glucose levels regularly.”
Rationale: Gestational diabetes requires dietary management and regular blood glucose
monitoring to ensure maternal and fetal health. It does not usually resolve until after delivery.
,4. A nurse is caring for a postpartum client who is 2 hours post-delivery. The client has a
firm, midline fundus and moderate lochia rubra. The nurse observes that the client’s pulse
rate is 110 beats per minute. Which of the following is the most appropriate action for the
nurse to take?
A. Administer a prescribed analgesic.
B. Increase oral fluid intake.
C. Monitor for signs of hypovolemia.
D. Assess the bladder for distention.
Answer: D. Assess the bladder for distention.
Rationale: A pulse rate of 110 beats per minute may indicate bladder distention, which is a
common cause of increased pulse postpartum. A distended bladder can displace the uterus and
interfere with uterine contraction, leading to bleeding.
5. A 25-year-old primigravida client at 39 weeks gestation is admitted with complaints of
decreased fetal movement. The nurse auscultates the fetal heart rate and hears a prolonged
deceleration pattern. What should be the nurse’s priority action?
A. Administer oxygen via face mask.
B. Reposition the client on her left side.
C. Prepare for a cesarean section.
D. Notify the healthcare provider.
Answer: B. Reposition the client on her left side.
Rationale: Repositioning the client can help relieve uterine pressure on major blood vessels,
improve uteroplacental circulation, and may resolve decelerations in fetal heart rate.
6. A nurse is caring for a postpartum client who is breastfeeding. Which of the following
interventions should the nurse recommend to promote successful breastfeeding?
A. Feed the baby every 3-4 hours.
B. Use a nipple shield to avoid nipple soreness.
C. Ensure the baby latches onto the entire nipple and areola.
D. Limit the duration of each feeding to 10-15 minutes.
Answer: C. Ensure the baby latches onto the entire nipple and areola.
Rationale: Proper latching is critical to prevent nipple soreness and ensure effective milk
transfer. The baby should latch onto the entire nipple and areola, not just the nipple.
, 7. A client at 12 weeks gestation is experiencing nausea and vomiting. Which of the
following is an appropriate nursing intervention?
A. Encourage the client to drink large amounts of fluid at once.
B. Suggest eating small, frequent meals high in fat.
C. Recommend the use of ginger or vitamin B6 to help alleviate symptoms.
D. Advise the client to avoid eating any food until the nausea resolves.
Answer: C. Recommend the use of ginger or vitamin B6 to help alleviate symptoms.
Rationale: Ginger and vitamin B6 are known to help alleviate nausea in pregnancy. Small,
frequent meals and adequate hydration are also recommended.
8. A nurse is teaching a postpartum client about self-care. Which of the following
statements by the client indicates an understanding of the teaching?
A. “I should use tampons until the bleeding stops.”
B. “I should perform pelvic floor exercises to prevent urinary incontinence.”
C. “I should avoid having any physical activity for 6 weeks.”
D. “I should increase my caloric intake while breastfeeding.”
Answer: B. “I should perform pelvic floor exercises to prevent urinary incontinence.”
Rationale: Pelvic floor exercises (Kegel exercises) are important postpartum to help strengthen
the pelvic muscles and prevent urinary incontinence. Tampons should be avoided in the early
postpartum period due to the risk of infection.
9. A nurse is caring for a client in labor who has a temperature of 101°F (38.3°C). Which of
the following actions should the nurse take first?
A. Administer acetaminophen as prescribed.
B. Increase fluid intake.
C. Obtain a urine sample for culture.
D. Assess the fetal heart rate.
Answer: D. Assess the fetal heart rate.
Rationale: A fever can affect fetal well-being, so the nurse should first assess fetal heart rate to
evaluate fetal response to maternal fever.
10. A nurse is preparing a 28-week gestation client for a glucose tolerance test. Which of
the following actions should the nurse take?
heartburn. Which of the following interventions should the nurse recommend to alleviate
this discomfort?
A. Eat large meals to avoid acid reflux.
B. Drink fluids with meals.
C. Sleep in a semi-reclining position.
D. Lie flat after meals.
Answer: C. Sleep in a semi-reclining position.
Rationale: Sleeping in a semi-reclining position helps reduce the risk of acid reflux, which is
common in pregnancy due to hormonal changes and the growing uterus pressing on the stomach.
2. A nurse is caring for a 32-week pregnant woman who is experiencing vaginal bleeding.
Which of the following actions should the nurse take first?
A. Perform a vaginal examination to assess for cervical dilation.
B. Assess the fetal heart rate.
C. Administer oxygen via face mask.
D. Prepare for immediate cesarean delivery.
Answer: B. Assess the fetal heart rate.
Rationale: The first priority is to assess the fetal heart rate to evaluate fetal well-being. Vaginal
bleeding can indicate complications like placenta previa or placental abruption, which require
prompt fetal monitoring.
3. A nurse is educating a pregnant woman about gestational diabetes. Which of the
following statements by the client indicates an understanding of the teaching?
A. “I will need to follow a special diet and check my blood glucose levels regularly.”
B. “I will probably need to take insulin during my pregnancy, but I can stop once the baby is
born.”
C. “Gestational diabetes usually goes away in the second trimester.”
D. “I should eat more high-sugar foods to keep my blood glucose levels stable.”
Answer: A. “I will need to follow a special diet and check my blood glucose levels regularly.”
Rationale: Gestational diabetes requires dietary management and regular blood glucose
monitoring to ensure maternal and fetal health. It does not usually resolve until after delivery.
,4. A nurse is caring for a postpartum client who is 2 hours post-delivery. The client has a
firm, midline fundus and moderate lochia rubra. The nurse observes that the client’s pulse
rate is 110 beats per minute. Which of the following is the most appropriate action for the
nurse to take?
A. Administer a prescribed analgesic.
B. Increase oral fluid intake.
C. Monitor for signs of hypovolemia.
D. Assess the bladder for distention.
Answer: D. Assess the bladder for distention.
Rationale: A pulse rate of 110 beats per minute may indicate bladder distention, which is a
common cause of increased pulse postpartum. A distended bladder can displace the uterus and
interfere with uterine contraction, leading to bleeding.
5. A 25-year-old primigravida client at 39 weeks gestation is admitted with complaints of
decreased fetal movement. The nurse auscultates the fetal heart rate and hears a prolonged
deceleration pattern. What should be the nurse’s priority action?
A. Administer oxygen via face mask.
B. Reposition the client on her left side.
C. Prepare for a cesarean section.
D. Notify the healthcare provider.
Answer: B. Reposition the client on her left side.
Rationale: Repositioning the client can help relieve uterine pressure on major blood vessels,
improve uteroplacental circulation, and may resolve decelerations in fetal heart rate.
6. A nurse is caring for a postpartum client who is breastfeeding. Which of the following
interventions should the nurse recommend to promote successful breastfeeding?
A. Feed the baby every 3-4 hours.
B. Use a nipple shield to avoid nipple soreness.
C. Ensure the baby latches onto the entire nipple and areola.
D. Limit the duration of each feeding to 10-15 minutes.
Answer: C. Ensure the baby latches onto the entire nipple and areola.
Rationale: Proper latching is critical to prevent nipple soreness and ensure effective milk
transfer. The baby should latch onto the entire nipple and areola, not just the nipple.
, 7. A client at 12 weeks gestation is experiencing nausea and vomiting. Which of the
following is an appropriate nursing intervention?
A. Encourage the client to drink large amounts of fluid at once.
B. Suggest eating small, frequent meals high in fat.
C. Recommend the use of ginger or vitamin B6 to help alleviate symptoms.
D. Advise the client to avoid eating any food until the nausea resolves.
Answer: C. Recommend the use of ginger or vitamin B6 to help alleviate symptoms.
Rationale: Ginger and vitamin B6 are known to help alleviate nausea in pregnancy. Small,
frequent meals and adequate hydration are also recommended.
8. A nurse is teaching a postpartum client about self-care. Which of the following
statements by the client indicates an understanding of the teaching?
A. “I should use tampons until the bleeding stops.”
B. “I should perform pelvic floor exercises to prevent urinary incontinence.”
C. “I should avoid having any physical activity for 6 weeks.”
D. “I should increase my caloric intake while breastfeeding.”
Answer: B. “I should perform pelvic floor exercises to prevent urinary incontinence.”
Rationale: Pelvic floor exercises (Kegel exercises) are important postpartum to help strengthen
the pelvic muscles and prevent urinary incontinence. Tampons should be avoided in the early
postpartum period due to the risk of infection.
9. A nurse is caring for a client in labor who has a temperature of 101°F (38.3°C). Which of
the following actions should the nurse take first?
A. Administer acetaminophen as prescribed.
B. Increase fluid intake.
C. Obtain a urine sample for culture.
D. Assess the fetal heart rate.
Answer: D. Assess the fetal heart rate.
Rationale: A fever can affect fetal well-being, so the nurse should first assess fetal heart rate to
evaluate fetal response to maternal fever.
10. A nurse is preparing a 28-week gestation client for a glucose tolerance test. Which of
the following actions should the nurse take?
