| Latest Version | 2025/2026 | Correct &
Verified
A client at 37 weeks gestation reports sudden abdominal pain and bright red vaginal bleeding.
What is the priority nursing action?
A. Encourage rest and monitor
✔✔B. Assess fetal heart rate and prepare for possible placental abruption
C. Administer analgesics
D. Measure fundal height
A postpartum client reports excessive lochia with large clots 3 hours after delivery. What is the
most appropriate intervention?
A. Document findings only
✔✔B. Massage the fundus and assess for uterine atony
C. Encourage ambulation
D. Apply cold compress
A client at 36 weeks gestation presents with headache, visual changes, and upper abdominal
pain. What condition should the nurse suspect?
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,A. Hyperemesis gravidarum
✔✔B. Preeclampsia
C. Gestational diabetes
D. Placenta previa
A newborn has a heart rate of 90 bpm, weak cry, and decreased muscle tone at 1 minute of life.
What is the priority nursing intervention?
A. Swaddle and monitor
✔✔B. Provide stimulation and supplemental oxygen
C. Administer vitamin K
D. Perform routine assessment later
A client in labor has contractions every 2 minutes, each lasting 90 seconds, with late
decelerations noted on the fetal monitor. What is the first nursing action?
A. Administer pain medication
✔✔B. Reposition the client, give oxygen, and notify the provider
C. Encourage deep breathing
D. Prepare for delivery
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,A postpartum client reports breast tenderness, redness, and fever on day 5. What is the most
likely cause?
A. Engorgement
✔✔B. Mastitis
C. Plugged duct
D. Normal postpartum changes
A client at 32 weeks gestation reports severe pruritus and dark urine. What is the priority nursing
assessment?
A. Check blood pressure
B. Assess for urinary tract infection
✔✔C. Assess for intrahepatic cholestasis of pregnancy
D. Encourage hydration
A client receiving oxytocin for induction develops contractions lasting 100 seconds with a
frequency of every 1–2 minutes. What is the priority nursing intervention?
A. Increase the infusion rate
✔✔B. Stop the oxytocin and notify the provider
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, C. Encourage rest
D. Administer analgesics
A newborn has jaundice and bilirubin of 18 mg/dL at 48 hours of life. What is the priority
nursing action?
A. Delay feeding
✔✔B. Initiate phototherapy and encourage frequent feeding
C. Provide only water
D. Reassess in 12 hours
A client in active labor reports sudden, severe back pain during contractions. What non-
pharmacologic intervention can the nurse suggest?
A. Apply cold to the abdomen
✔✔B. Encourage position changes, ambulation, and counter-pressure
C. Limit movement and keep supine
D. Provide IV opioids immediately
A client at 40 weeks gestation presents with rupture of membranes. What is the priority nursing
action?
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