1. A nurse is providing education to a pregnant woman in her first trimester.
Which of the following statements by the patient indicates a need for further
teaching?
A) "I should avoid drinking caffeinated beverages."
B) "I should not take any medication without consulting my doctor."
C) "I need to limit my physical activity to avoid overexertion."
D) "I should increase my caloric intake by 500 calories per day."
Answer: D) "I should increase my caloric intake by 500 calories per day."
Rationale: In the first trimester, calorie intake should remain about the same as before
pregnancy. Increased caloric intake is typically recommended in the second and third trimesters.
2. A nurse is caring for a postpartum patient who is 24 hours post-delivery. The
nurse notes that the patient’s lochia is bright red and heavy. Which of the
following is the appropriate nursing intervention?
A) Administer a dose of oxytocin.
B) Assess the uterus for firmness and position.
C) Encourage the patient to ambulate frequently.
D) Apply a cold compress to the perineum.
Answer: B) Assess the uterus for firmness and position.
Rationale: Heavy lochia with bright red color in the first 24 hours after delivery is typically
normal, but it’s essential to assess for uterine atony (a soft, boggy uterus), which can lead to
hemorrhage.
3. A nurse is caring for a neonate who was delivered via cesarean section. The
nurse observes the neonate’s respiratory rate is 70 breaths per minute. Which of
the following actions should the nurse take?
A) Document the finding as normal.
B) Notify the healthcare provider immediately.
C) Place the neonate under a warmer.
D) Administer oxygen as ordered.
Answer: A) Document the finding as normal.
Rationale: Newborns, especially those delivered via cesarean, may exhibit a higher respiratory
rate (up to 60-70 breaths/min) in the first few hours. This is usually transient and should be
monitored.
,4. A nurse is assessing a newborn shortly after birth. Which of the following
findings should the nurse report to the healthcare provider immediately?
A) Heart rate of 140 beats per minute
B) Respiratory rate of 60 breaths per minute
C) Cyanosis of the hands and feet
D) Grunting with each breath
Answer: D) Grunting with each breath
Rationale: Grunting is a sign of respiratory distress and may indicate the need for immediate
intervention, such as assessment for potential conditions like neonatal respiratory distress
syndrome.
5. A nurse is teaching a pregnant client about nutrition. Which of the following
statements indicates that the client understands the teaching about folic acid?
A) "I will take 400 mcg of folic acid every day."
B) "I will take 1,000 mcg of folic acid every day."
C) "I can get enough folic acid from my diet alone, so I do not need supplements."
D) "Folic acid should only be taken during the first trimester."
Answer: A) "I will take 400 mcg of folic acid every day."
Rationale: It is recommended that pregnant women take 400 mcg of folic acid daily, starting
before conception and continuing through the first trimester to prevent neural tube defects.
6. The nurse is caring for a client at 39 weeks of gestation who presents with
painless, bright red vaginal bleeding. The nurse suspects which of the following
conditions?
A) Placenta previa
B) Placental abruption
C) Uterine rupture
D) Spontaneous abortion
Answer: A) Placenta previa
Rationale: Placenta previa typically presents with painless, bright red vaginal bleeding in the
third trimester. In contrast, placental abruption presents with pain and dark red bleeding.
, 7. A nurse is caring for a 3-day-old neonate who is being formula-fed. The nurse
notes that the infant’s stool is yellow and pasty. Which of the following is the
appropriate interpretation of this finding?
A) The infant is having diarrhea.
B) The stool is normal for a formula-fed infant.
C) The infant is showing signs of jaundice.
D) The stool is indicative of a gastrointestinal infection.
Answer: B) The stool is normal for a formula-fed infant.
Rationale: Formula-fed infants typically have yellow, pasty stools. Breastfed infants often have
more mustard-colored stools.
8. A nurse is providing teaching to a client who is pregnant and has gestational
hypertension. Which of the following should the nurse include in the teaching
plan?
A) "Monitor your blood pressure at home daily."
B) "You should avoid bed rest to prevent complications."
C) "Increase your salt intake to help with fluid balance."
D) "Gestational hypertension will resolve after delivery."
Answer: A) "Monitor your blood pressure at home daily."
Rationale: Clients with gestational hypertension should monitor their blood pressure regularly.
The condition may resolve after delivery, but monitoring is essential to identify any
complications.
9. A nurse is caring for a client who is experiencing preterm labor at 32 weeks of
gestation. Which of the following interventions should the nurse anticipate?
A) Administering magnesium sulfate to stop contractions.
B) Encouraging the client to ambulate to facilitate labor.
C) Administering oxytocin to induce labor.
D) Instructing the client to rest and refrain from activity.
Answer: A) Administering magnesium sulfate to stop contractions.
Rationale: Magnesium sulfate is commonly used to relax the uterus and stop preterm labor. Bed
rest and activity restriction are also common interventions but not as a first-line option.
Which of the following statements by the patient indicates a need for further
teaching?
A) "I should avoid drinking caffeinated beverages."
B) "I should not take any medication without consulting my doctor."
C) "I need to limit my physical activity to avoid overexertion."
D) "I should increase my caloric intake by 500 calories per day."
Answer: D) "I should increase my caloric intake by 500 calories per day."
Rationale: In the first trimester, calorie intake should remain about the same as before
pregnancy. Increased caloric intake is typically recommended in the second and third trimesters.
2. A nurse is caring for a postpartum patient who is 24 hours post-delivery. The
nurse notes that the patient’s lochia is bright red and heavy. Which of the
following is the appropriate nursing intervention?
A) Administer a dose of oxytocin.
B) Assess the uterus for firmness and position.
C) Encourage the patient to ambulate frequently.
D) Apply a cold compress to the perineum.
Answer: B) Assess the uterus for firmness and position.
Rationale: Heavy lochia with bright red color in the first 24 hours after delivery is typically
normal, but it’s essential to assess for uterine atony (a soft, boggy uterus), which can lead to
hemorrhage.
3. A nurse is caring for a neonate who was delivered via cesarean section. The
nurse observes the neonate’s respiratory rate is 70 breaths per minute. Which of
the following actions should the nurse take?
A) Document the finding as normal.
B) Notify the healthcare provider immediately.
C) Place the neonate under a warmer.
D) Administer oxygen as ordered.
Answer: A) Document the finding as normal.
Rationale: Newborns, especially those delivered via cesarean, may exhibit a higher respiratory
rate (up to 60-70 breaths/min) in the first few hours. This is usually transient and should be
monitored.
,4. A nurse is assessing a newborn shortly after birth. Which of the following
findings should the nurse report to the healthcare provider immediately?
A) Heart rate of 140 beats per minute
B) Respiratory rate of 60 breaths per minute
C) Cyanosis of the hands and feet
D) Grunting with each breath
Answer: D) Grunting with each breath
Rationale: Grunting is a sign of respiratory distress and may indicate the need for immediate
intervention, such as assessment for potential conditions like neonatal respiratory distress
syndrome.
5. A nurse is teaching a pregnant client about nutrition. Which of the following
statements indicates that the client understands the teaching about folic acid?
A) "I will take 400 mcg of folic acid every day."
B) "I will take 1,000 mcg of folic acid every day."
C) "I can get enough folic acid from my diet alone, so I do not need supplements."
D) "Folic acid should only be taken during the first trimester."
Answer: A) "I will take 400 mcg of folic acid every day."
Rationale: It is recommended that pregnant women take 400 mcg of folic acid daily, starting
before conception and continuing through the first trimester to prevent neural tube defects.
6. The nurse is caring for a client at 39 weeks of gestation who presents with
painless, bright red vaginal bleeding. The nurse suspects which of the following
conditions?
A) Placenta previa
B) Placental abruption
C) Uterine rupture
D) Spontaneous abortion
Answer: A) Placenta previa
Rationale: Placenta previa typically presents with painless, bright red vaginal bleeding in the
third trimester. In contrast, placental abruption presents with pain and dark red bleeding.
, 7. A nurse is caring for a 3-day-old neonate who is being formula-fed. The nurse
notes that the infant’s stool is yellow and pasty. Which of the following is the
appropriate interpretation of this finding?
A) The infant is having diarrhea.
B) The stool is normal for a formula-fed infant.
C) The infant is showing signs of jaundice.
D) The stool is indicative of a gastrointestinal infection.
Answer: B) The stool is normal for a formula-fed infant.
Rationale: Formula-fed infants typically have yellow, pasty stools. Breastfed infants often have
more mustard-colored stools.
8. A nurse is providing teaching to a client who is pregnant and has gestational
hypertension. Which of the following should the nurse include in the teaching
plan?
A) "Monitor your blood pressure at home daily."
B) "You should avoid bed rest to prevent complications."
C) "Increase your salt intake to help with fluid balance."
D) "Gestational hypertension will resolve after delivery."
Answer: A) "Monitor your blood pressure at home daily."
Rationale: Clients with gestational hypertension should monitor their blood pressure regularly.
The condition may resolve after delivery, but monitoring is essential to identify any
complications.
9. A nurse is caring for a client who is experiencing preterm labor at 32 weeks of
gestation. Which of the following interventions should the nurse anticipate?
A) Administering magnesium sulfate to stop contractions.
B) Encouraging the client to ambulate to facilitate labor.
C) Administering oxytocin to induce labor.
D) Instructing the client to rest and refrain from activity.
Answer: A) Administering magnesium sulfate to stop contractions.
Rationale: Magnesium sulfate is commonly used to relax the uterus and stop preterm labor. Bed
rest and activity restriction are also common interventions but not as a first-line option.
