NURS240 Maternal-Newborn Nursing Updated 2026 |
Comprehensive Study Guide, Practice Exam Questions and
Answers, Exam Prep Test Bank, Prenatal and Antenatal Care,
Labor and Delivery Nursing Management, Postpartum Assessment
and Recovery, Newborn and Neonatal Nursing Care, High-Risk
Pregnancy Complications, Maternal Pharmacology, Breastfeeding
Support, Family-Centered Care, and Detailed Rationales for
Nursing Exam Success
Question 1: A 32-week gestation primigravida presents with a blood pressure of
150/96 mmHg and 3+ proteinuria on a urine dipstick. Which assessment finding is
most indicative of severe preeclampsia rather than mild preeclampsia?
A. Facial edema
B. Blood pressure of 150/96 mmHg
C. Hyperreflexia with clonus
D. Weight gain of 2 pounds in one week
CORRECT ANSWER: C. Hyperreflexia with clonus
Rationale: Severe preeclampsia is characterized by significant end-organ dysfunction.
Hyperreflexia and clonus indicate central nervous system irritability and an increased
risk of seizures (eclampsia). While elevated blood pressure and proteinuria are
diagnostic criteria for preeclampsia, the severity is defined by the presence of severe
features such as neurologic symptoms (headache, visual changes, hyperreflexia),
hepatic impairment, thrombocytopenia, or renal insufficiency.
Question 2: A postpartum client who had a cesarean birth 12 hours ago reports
sudden sharp chest pain and shortness of breath. Her heart rate is 120 bpm, and
respiratory rate is 28 breaths/min. What is the nurse's priority action?
A. Administer prescribed PRN pain medication
B. Encourage incentive spirometry use
C. Apply a sequential compression device
D. Notify the healthcare provider immediately
CORRECT ANSWER: D. Notify the healthcare provider immediately
Rationale: The sudden onset of chest pain, tachypnea, and tachycardia in a
postpartum patient is highly suspicious for a pulmonary embolism (PE). This is a life-
threatening obstetric emergency. The nurse's priority is to immediately notify the
healthcare provider and prepare for diagnostic testing and potential interventions. Pain
medication would mask symptoms, and the other options are not appropriate first-line
responses for a suspected PE.
,Question 3: During the active phase of the first stage of labor, a fetal heart rate
(FHR) tracing shows recurrent late decelerations. What is the underlying
physiological cause of this pattern?
A. Head compression
B. Umbilical cord compression
C. Uteroplacental insufficiency
D. Fetal sleep cycle
CORRECT ANSWER: C. Uteroplacental insufficiency
Rationale: Late decelerations are a sign of uteroplacental insufficiency, where oxygen
transfer to the fetus is compromised. They are characterized by a gradual decrease in
FHR that begins after the peak of the uterine contraction and returns to baseline after
the contraction ends. This pattern is non-reassuring and requires immediate
interventions to improve placental perfusion, such as maternal repositioning and
oxygen administration.
Question 4: A nurse is providing education to a new mother on infant bathing.
Which statement by the mother indicates a correct understanding of the teaching?
A. "I will give my baby a sponge bath until the umbilical cord falls off."
B. "I will use warm water and antibacterial soap for the bath."
C. "I should bathe my baby every day to keep them clean."
D. "I will bathe my baby immediately after a feeding."
CORRECT ANSWER: A. "I will give my baby a sponge bath until the umbilical cord
falls off."
Rationale: Sponge baths are recommended until the umbilical cord stump falls off and
the circumcision (if performed) has healed to prevent infection. Newborns do not
require daily baths; 2-3 times per week is sufficient. Plain warm water is generally
preferred over soaps, which can dry out the infant's skin. Bathing should be done before
a feeding to prevent spitting up.
Question 5: A client at 38 weeks gestation is being induced with oxytocin. Which
clinical manifestation would prompt the nurse to immediately stop the infusion?
A. Fetal heart rate of 140 bpm with moderate variability
B. Maternal heart rate increase from 80 to 100 bpm
C. Uterine contractions every 2 minutes lasting 60 seconds
D. Uterine contractions lasting 100 seconds with a resting tone of 30 mmHg
,CORRECT ANSWER: D. Uterine contractions lasting 100 seconds with a resting tone
of 30 mmHg
Rationale: Oxytocin can cause hyperstimulation of the uterus, leading to contractions
that are too frequent, prolonged, or have an elevated resting tone. A resting tone of >20
mmHg and contractions lasting >90 seconds are signs of hyperstimulation, which can
compromise uteroplacental blood flow and lead to fetal distress. The infusion must be
stopped immediately.
Question 6: When assessing a 28-week gestation client with gestational diabetes,
which laboratory finding is most concerning and requires immediate intervention?
A. Hemoglobin A1c of 6.0%
B. Random blood glucose of 140 mg/dL
C. 2-hour postprandial blood glucose of 135 mg/dL
D. Fasting blood glucose of 95 mg/dL
CORRECT ANSWER: A. Hemoglobin A1c of 6.0%
Rationale: While all values represent some degree of hyperglycemia, an A1c of 6.0% in
a pregnant woman indicates poor glycemic control over the preceding 2-3 months.
Targets for gestational diabetes are often <5.8-6.0%. Elevated A1c is strongly associated
with congenital anomalies and macrosomia. While the other glucose values are
elevated, the A1c reflects a chronic issue.
Question 7: A nurse is caring for a postpartum client who received epidural
anesthesia during labor. Which assessment finding indicates a potential
complication of the epidural?
A. Mild headache when lying flat
B. Leg weakness for 2 hours post-birth
C. Urinary retention
D. Severe headache that worsens when sitting upright
CORRECT ANSWER: D. Severe headache that worsens when sitting upright
Rationale: A severe headache that worsens when sitting or standing and improves
when lying flat is a classic symptom of a post-dural puncture headache (PDPH). This
occurs due to leakage of cerebrospinal fluid through the puncture site. While urinary
retention and leg weakness can occur with an epidural, a headache that worsens with
an upright position is the hallmark sign of a PDPH.
Question 8: A newborn's Apgar scores are 6 at 1 minute and 8 at 5 minutes. What
does this change indicate about the newborn's condition?
, A. The newborn is showing signs of respiratory distress.
B. The newborn's condition is improving, requiring only routine post-resuscitative care.
C. The newborn experienced a significant hypoxic event.
D. The newborn is likely suffering from a congenital anomaly.
CORRECT ANSWER: B. The newborn's condition is improving, requiring only routine
post-resuscitative care.
Rationale: An Apgar score of 6 at 1 minute indicates the newborn needs some
resuscitative measures, while a score of 8 at 5 minutes is normal and indicates the
infant is responding well to interventions. This shows clinical improvement. A score
below 7 at 5 minutes would warrant further evaluation and continued resuscitation.
Question 9: A term newborn is noted to have a swollen, edematous area on the
right side of the scalp that does not cross the suture line. How should the nurse
document this finding?
A. Caput succedaneum
B. Cephalohematoma
C. Subgaleal hemorrhage
D. Molding
CORRECT ANSWER: B. Cephalohematoma
Rationale: A cephalohematoma is a collection of blood between the periosteum and
the skull bone. It is characterized by a swelling that does not cross the suture lines. This
is typically caused by pressure during birth and resolves spontaneously over weeks to
months. Caput succedaneum crosses suture lines and is a diffuse swelling of the soft
tissue of the scalp.
Question 10: A client in the third trimester of pregnancy reports frequent heartburn.
What instruction should the nurse provide to alleviate this symptom?
A. Drink plenty of fluids with meals.
B. Lie down immediately after eating.
C. Eat small, frequent meals throughout the day.
D. Consume spicy foods to aid digestion.
CORRECT ANSWER: C. Eat small, frequent meals throughout the day.
Rationale: Heartburn during pregnancy is caused by hormonal relaxation of the cardiac
sphincter and the growing uterus pushing against the stomach. Eating small, frequent
meals prevents the stomach from becoming overly full, reducing acid reflux. Fluids
should be taken between meals, and the client should remain upright after eating.
Comprehensive Study Guide, Practice Exam Questions and
Answers, Exam Prep Test Bank, Prenatal and Antenatal Care,
Labor and Delivery Nursing Management, Postpartum Assessment
and Recovery, Newborn and Neonatal Nursing Care, High-Risk
Pregnancy Complications, Maternal Pharmacology, Breastfeeding
Support, Family-Centered Care, and Detailed Rationales for
Nursing Exam Success
Question 1: A 32-week gestation primigravida presents with a blood pressure of
150/96 mmHg and 3+ proteinuria on a urine dipstick. Which assessment finding is
most indicative of severe preeclampsia rather than mild preeclampsia?
A. Facial edema
B. Blood pressure of 150/96 mmHg
C. Hyperreflexia with clonus
D. Weight gain of 2 pounds in one week
CORRECT ANSWER: C. Hyperreflexia with clonus
Rationale: Severe preeclampsia is characterized by significant end-organ dysfunction.
Hyperreflexia and clonus indicate central nervous system irritability and an increased
risk of seizures (eclampsia). While elevated blood pressure and proteinuria are
diagnostic criteria for preeclampsia, the severity is defined by the presence of severe
features such as neurologic symptoms (headache, visual changes, hyperreflexia),
hepatic impairment, thrombocytopenia, or renal insufficiency.
Question 2: A postpartum client who had a cesarean birth 12 hours ago reports
sudden sharp chest pain and shortness of breath. Her heart rate is 120 bpm, and
respiratory rate is 28 breaths/min. What is the nurse's priority action?
A. Administer prescribed PRN pain medication
B. Encourage incentive spirometry use
C. Apply a sequential compression device
D. Notify the healthcare provider immediately
CORRECT ANSWER: D. Notify the healthcare provider immediately
Rationale: The sudden onset of chest pain, tachypnea, and tachycardia in a
postpartum patient is highly suspicious for a pulmonary embolism (PE). This is a life-
threatening obstetric emergency. The nurse's priority is to immediately notify the
healthcare provider and prepare for diagnostic testing and potential interventions. Pain
medication would mask symptoms, and the other options are not appropriate first-line
responses for a suspected PE.
,Question 3: During the active phase of the first stage of labor, a fetal heart rate
(FHR) tracing shows recurrent late decelerations. What is the underlying
physiological cause of this pattern?
A. Head compression
B. Umbilical cord compression
C. Uteroplacental insufficiency
D. Fetal sleep cycle
CORRECT ANSWER: C. Uteroplacental insufficiency
Rationale: Late decelerations are a sign of uteroplacental insufficiency, where oxygen
transfer to the fetus is compromised. They are characterized by a gradual decrease in
FHR that begins after the peak of the uterine contraction and returns to baseline after
the contraction ends. This pattern is non-reassuring and requires immediate
interventions to improve placental perfusion, such as maternal repositioning and
oxygen administration.
Question 4: A nurse is providing education to a new mother on infant bathing.
Which statement by the mother indicates a correct understanding of the teaching?
A. "I will give my baby a sponge bath until the umbilical cord falls off."
B. "I will use warm water and antibacterial soap for the bath."
C. "I should bathe my baby every day to keep them clean."
D. "I will bathe my baby immediately after a feeding."
CORRECT ANSWER: A. "I will give my baby a sponge bath until the umbilical cord
falls off."
Rationale: Sponge baths are recommended until the umbilical cord stump falls off and
the circumcision (if performed) has healed to prevent infection. Newborns do not
require daily baths; 2-3 times per week is sufficient. Plain warm water is generally
preferred over soaps, which can dry out the infant's skin. Bathing should be done before
a feeding to prevent spitting up.
Question 5: A client at 38 weeks gestation is being induced with oxytocin. Which
clinical manifestation would prompt the nurse to immediately stop the infusion?
A. Fetal heart rate of 140 bpm with moderate variability
B. Maternal heart rate increase from 80 to 100 bpm
C. Uterine contractions every 2 minutes lasting 60 seconds
D. Uterine contractions lasting 100 seconds with a resting tone of 30 mmHg
,CORRECT ANSWER: D. Uterine contractions lasting 100 seconds with a resting tone
of 30 mmHg
Rationale: Oxytocin can cause hyperstimulation of the uterus, leading to contractions
that are too frequent, prolonged, or have an elevated resting tone. A resting tone of >20
mmHg and contractions lasting >90 seconds are signs of hyperstimulation, which can
compromise uteroplacental blood flow and lead to fetal distress. The infusion must be
stopped immediately.
Question 6: When assessing a 28-week gestation client with gestational diabetes,
which laboratory finding is most concerning and requires immediate intervention?
A. Hemoglobin A1c of 6.0%
B. Random blood glucose of 140 mg/dL
C. 2-hour postprandial blood glucose of 135 mg/dL
D. Fasting blood glucose of 95 mg/dL
CORRECT ANSWER: A. Hemoglobin A1c of 6.0%
Rationale: While all values represent some degree of hyperglycemia, an A1c of 6.0% in
a pregnant woman indicates poor glycemic control over the preceding 2-3 months.
Targets for gestational diabetes are often <5.8-6.0%. Elevated A1c is strongly associated
with congenital anomalies and macrosomia. While the other glucose values are
elevated, the A1c reflects a chronic issue.
Question 7: A nurse is caring for a postpartum client who received epidural
anesthesia during labor. Which assessment finding indicates a potential
complication of the epidural?
A. Mild headache when lying flat
B. Leg weakness for 2 hours post-birth
C. Urinary retention
D. Severe headache that worsens when sitting upright
CORRECT ANSWER: D. Severe headache that worsens when sitting upright
Rationale: A severe headache that worsens when sitting or standing and improves
when lying flat is a classic symptom of a post-dural puncture headache (PDPH). This
occurs due to leakage of cerebrospinal fluid through the puncture site. While urinary
retention and leg weakness can occur with an epidural, a headache that worsens with
an upright position is the hallmark sign of a PDPH.
Question 8: A newborn's Apgar scores are 6 at 1 minute and 8 at 5 minutes. What
does this change indicate about the newborn's condition?
, A. The newborn is showing signs of respiratory distress.
B. The newborn's condition is improving, requiring only routine post-resuscitative care.
C. The newborn experienced a significant hypoxic event.
D. The newborn is likely suffering from a congenital anomaly.
CORRECT ANSWER: B. The newborn's condition is improving, requiring only routine
post-resuscitative care.
Rationale: An Apgar score of 6 at 1 minute indicates the newborn needs some
resuscitative measures, while a score of 8 at 5 minutes is normal and indicates the
infant is responding well to interventions. This shows clinical improvement. A score
below 7 at 5 minutes would warrant further evaluation and continued resuscitation.
Question 9: A term newborn is noted to have a swollen, edematous area on the
right side of the scalp that does not cross the suture line. How should the nurse
document this finding?
A. Caput succedaneum
B. Cephalohematoma
C. Subgaleal hemorrhage
D. Molding
CORRECT ANSWER: B. Cephalohematoma
Rationale: A cephalohematoma is a collection of blood between the periosteum and
the skull bone. It is characterized by a swelling that does not cross the suture lines. This
is typically caused by pressure during birth and resolves spontaneously over weeks to
months. Caput succedaneum crosses suture lines and is a diffuse swelling of the soft
tissue of the scalp.
Question 10: A client in the third trimester of pregnancy reports frequent heartburn.
What instruction should the nurse provide to alleviate this symptom?
A. Drink plenty of fluids with meals.
B. Lie down immediately after eating.
C. Eat small, frequent meals throughout the day.
D. Consume spicy foods to aid digestion.
CORRECT ANSWER: C. Eat small, frequent meals throughout the day.
Rationale: Heartburn during pregnancy is caused by hormonal relaxation of the cardiac
sphincter and the growing uterus pushing against the stomach. Eating small, frequent
meals prevents the stomach from becoming overly full, reducing acid reflux. Fluids
should be taken between meals, and the client should remain upright after eating.
