NCLEX-PN Maternal-Newborn Nursing Practice Exam PDF | Questions,
Answers, and Detailed Rationales | Antepartum, Intrapartum, and
Postpartum Care, Maternal and Fetal Assessment, Labor and Delivery
Management, Newborn Assessment, Obstetric Complications,
Pharmacology in Maternal-Newborn Nursing, Patient Education, Family-
Centered Care, and Evidence-Based Clinical Decision-Making |
Comprehensive NCLEX-PN Exam Preparation Guide for Practical Nursing
Students
Question 1: A nurse is caring for a client who is at 32 weeks of gestation and reports
sudden, painless vaginal bleeding. Which of the following conditions should the
nurse suspect?
A. Placenta previa
B. Abruptio placentae
C. Uterine rupture
D. Cervical insufficiency
CORRECT ANSWER: A. Placenta previa
Rationale: Painless, bright red vaginal bleeding in the second or third trimester is the
hallmark sign of placenta previa, where the placenta covers the cervical os. Abruptio
placentae typically presents with painful bleeding and a rigid uterus. Uterine rupture is
associated with severe pain and loss of fetal station, usually during labor. Cervical
insufficiency involves painless dilation but not typically significant bleeding.
Question 2: A licensed practical nurse (LPN) is assisting with the admission of a
client in active labor. The fetal monitor shows late decelerations. What is the
priority nursing action?
A. Administer oxygen via nonrebreather mask
B. Increase the rate of the IV infusion
C. Place the client in a supine position
D. Prepare for immediate cesarean section
CORRECT ANSWER: A. Administer oxygen via nonrebreather mask
Rationale: Late decelerations indicate uteroplacental insufficiency and fetal hypoxia.
The priority is to improve fetal oxygenation by administering oxygen, changing the
maternal position (usually to lateral), and stopping oxytocin if running. While preparing
for a C-section may become necessary, the immediate nursing intervention is to
optimize fetal status. Supine positioning can worsen the situation due to vena cava
compression.
Question 3: A newborn is assessed 1 minute after birth. The heart rate is 90/min,
respirations are slow and irregular, muscle tone is flaccid, there is no response to
suctioning, and the body is pink with blue extremities. What is the APGAR score?
,A. 3
B. 4
C. 5
D. 6
CORRECT ANSWER: B. 4
Rationale: The APGAR scoring is as follows: Heart rate <100 (1 point), Slow/irregular
respirations (1 point), Flaccid muscle tone (0 points), No response to stimulation (0
points), and Acrocyanosis (body pink, extremities blue) (1 point). Total score = 1 + 1 + 0 +
0 + 1 = 3. Wait, let me re-evaluate. Heart rate 90 is 1. Respirations slow/irregular is 1.
Tone flaccid is 0. Grimace/response is 0. Color acrocyanosis is 1. Total is 3. Let me re-
read the options. Ah, I see a calculation error in my thought process. Let's re-verify
standard scoring. HR <100 = 1. Resp slow/irregular = 1. Tone flaccid = 0. Reflex
irritability (no response) = 0. Color (acrocyanosis) = 1. Sum = 3. Option A is 3. Why did I
select B? Let me correct the question or answer. Actually, let's adjust the scenario
slightly to make the answer 4 to match typical exam variability or stick to the math. Math
is king. HR 90 (1), Resp slow (1), Tone flaccid (0), Reflex none (0), Color acrocyanosis (1).
Total 3. The correct option must be A. I will correct the bolded answer to A. CORRECT
ANSWER: A. 3
Rationale: The APGAR components are: Heart rate (90/min = 1 point), Respiratory effort
(slow/irregular = 1 point), Muscle tone (flaccid = 0 points), Reflex irritability (no response
= 0 points), and Color (acrocyanosis = 1 point). The sum is 3. A score of 3 indicates
significant distress requiring immediate resuscitation.
Question 4: A client at 10 weeks of gestation asks the nurse about dietary sources
of folic acid to prevent neural tube defects. Which food should the nurse
recommend?
A. Red meat
B. Fortified cereals
C. Milk products
D. Citrus fruits
CORRECT ANSWER: B. Fortified cereals
Rationale: Folic acid (folate) is crucial for preventing neural tube defects. While citrus
fruits and leafy greens contain natural folate, fortified cereals and grains are among the
richest and most reliable sources of synthetic folic acid recommended for pregnant
women. Red meat is high in iron, and milk products are high in calcium.
Question 5: A nurse is teaching a client about the signs of preeclampsia. Which
statement by the client indicates a need for further teaching?
A. "I should call the doctor if I have a severe headache."
B. "Swelling in my face and hands is a warning sign."
,C. "I will monitor my weight gain weekly."
D. "Increased energy levels are a symptom I should watch for."
CORRECT ANSWER: D. "Increased energy levels are a symptom I should watch for."
Rationale: Symptoms of preeclampsia include severe headache, visual disturbances,
epigastric pain, and sudden edema of the face and hands. Increased energy is not a
symptom; rather, patients often feel unwell. Recognizing that increased energy is not a
sign indicates the client needs correction if they think it is a warning sign, or if the
statement implies they believe it is a symptom, it shows a misunderstanding. The
question asks for a statement indicating a need for further teaching. If the client says
"Increased energy levels are a symptom," that is false, so they need teaching.
Question 6: A newborn born to a diabetic mother is at highest risk for which
condition immediately after birth?
A. Hyperglycemia
B. Hypoglycemia
C. Hypercalcemia
D. Hypobilirubinemia
CORRECT ANSWER: B. Hypoglycemia
Rationale: Infants of diabetic mothers (IDM) are exposed to high maternal glucose levels
in utero, leading to fetal hyperinsulinemia. Upon birth, the maternal glucose supply is
cut off, but the infant's insulin levels remain high, causing rapid depletion of blood
glucose (hypoglycemia). They are also at risk for hypocalcemia and hyperbilirubinemia,
but hypoglycemia is the most immediate and common metabolic risk.
Question 7: A client receiving magnesium sulfate for severe preeclampsia has a
respiratory rate of 10/min and absent deep tendon reflexes. What is the priority
action by the nurse?
A. Administer a bolus of magnesium sulfate
B. Check the blood pressure
C. Stop the magnesium sulfate infusion
D. Encourage the client to deep breathe
CORRECT ANSWER: C. Stop the magnesium sulfate infusion
Rationale: Signs of magnesium toxicity include respiratory depression (<12/min), absent
deep tendon reflexes, and oliguria. The priority action is to stop the infusion
immediately to prevent respiratory arrest. Calcium gluconate should be available as an
antidote. Checking BP is important but secondary to stopping the toxic agent.
Question 8: During a prenatal visit, a client at 20 weeks gestation reports feeling
fluttering sensations in her abdomen. How should the nurse document this
finding?
, A. Lightening
B. Ballottement
C. Quickening
D. Engagement
CORRECT ANSWER: C. Quickening
Rationale: Quickening is the term used to describe the mother's first perception of fetal
movement, typically occurring between 16 and 20 weeks of gestation. Lightening refers
to the fetus dropping into the pelvis. Ballottement is a passive fetal movement felt
during examination. Engagement is the entry of the fetal presenting part into the pelvic
inlet.
Question 9: A nurse is caring for a client with hyperemesis gravidarum. Which
laboratory value should the nurse monitor closely?
A. Serum potassium
B. Urine ketones
C. Hemoglobin
D. White blood cell count
CORRECT ANSWER: B. Urine ketones
Rationale: Hyperemesis gravidarum involves severe nausea and vomiting leading to
dehydration and starvation. The body breaks down fat stores for energy, resulting in the
production of ketones, which appear in the urine (ketonuria). While electrolyte
imbalances like hypokalemia are also concerns, ketonuria is a direct indicator of the
severity of starvation and dehydration in this context.
Question 10: A client in labor requests a non-pharmacological method to relieve
back pain caused by a fetus in the occiput posterior position. Which technique
should the nurse suggest?
A. Effleurage
B. Counterpressure
C. Guided imagery
D. Biofeedback
CORRECT ANSWER: B. Counterpressure
Rationale: Back labor, often associated with the occiput posterior (OP) position, causes
intense lower back pain. Applying counterpressure (firm pressure) to the sacral area
helps alleviate this specific type of pain. Effleurage is light stroking, guided imagery and
biofeedback are cognitive techniques, which are helpful but less specific for
mechanical back pain than counterpressure.
Question 11: A newborn is noted to have a Moro reflex. How should the nurse elicit
this reflex?
Answers, and Detailed Rationales | Antepartum, Intrapartum, and
Postpartum Care, Maternal and Fetal Assessment, Labor and Delivery
Management, Newborn Assessment, Obstetric Complications,
Pharmacology in Maternal-Newborn Nursing, Patient Education, Family-
Centered Care, and Evidence-Based Clinical Decision-Making |
Comprehensive NCLEX-PN Exam Preparation Guide for Practical Nursing
Students
Question 1: A nurse is caring for a client who is at 32 weeks of gestation and reports
sudden, painless vaginal bleeding. Which of the following conditions should the
nurse suspect?
A. Placenta previa
B. Abruptio placentae
C. Uterine rupture
D. Cervical insufficiency
CORRECT ANSWER: A. Placenta previa
Rationale: Painless, bright red vaginal bleeding in the second or third trimester is the
hallmark sign of placenta previa, where the placenta covers the cervical os. Abruptio
placentae typically presents with painful bleeding and a rigid uterus. Uterine rupture is
associated with severe pain and loss of fetal station, usually during labor. Cervical
insufficiency involves painless dilation but not typically significant bleeding.
Question 2: A licensed practical nurse (LPN) is assisting with the admission of a
client in active labor. The fetal monitor shows late decelerations. What is the
priority nursing action?
A. Administer oxygen via nonrebreather mask
B. Increase the rate of the IV infusion
C. Place the client in a supine position
D. Prepare for immediate cesarean section
CORRECT ANSWER: A. Administer oxygen via nonrebreather mask
Rationale: Late decelerations indicate uteroplacental insufficiency and fetal hypoxia.
The priority is to improve fetal oxygenation by administering oxygen, changing the
maternal position (usually to lateral), and stopping oxytocin if running. While preparing
for a C-section may become necessary, the immediate nursing intervention is to
optimize fetal status. Supine positioning can worsen the situation due to vena cava
compression.
Question 3: A newborn is assessed 1 minute after birth. The heart rate is 90/min,
respirations are slow and irregular, muscle tone is flaccid, there is no response to
suctioning, and the body is pink with blue extremities. What is the APGAR score?
,A. 3
B. 4
C. 5
D. 6
CORRECT ANSWER: B. 4
Rationale: The APGAR scoring is as follows: Heart rate <100 (1 point), Slow/irregular
respirations (1 point), Flaccid muscle tone (0 points), No response to stimulation (0
points), and Acrocyanosis (body pink, extremities blue) (1 point). Total score = 1 + 1 + 0 +
0 + 1 = 3. Wait, let me re-evaluate. Heart rate 90 is 1. Respirations slow/irregular is 1.
Tone flaccid is 0. Grimace/response is 0. Color acrocyanosis is 1. Total is 3. Let me re-
read the options. Ah, I see a calculation error in my thought process. Let's re-verify
standard scoring. HR <100 = 1. Resp slow/irregular = 1. Tone flaccid = 0. Reflex
irritability (no response) = 0. Color (acrocyanosis) = 1. Sum = 3. Option A is 3. Why did I
select B? Let me correct the question or answer. Actually, let's adjust the scenario
slightly to make the answer 4 to match typical exam variability or stick to the math. Math
is king. HR 90 (1), Resp slow (1), Tone flaccid (0), Reflex none (0), Color acrocyanosis (1).
Total 3. The correct option must be A. I will correct the bolded answer to A. CORRECT
ANSWER: A. 3
Rationale: The APGAR components are: Heart rate (90/min = 1 point), Respiratory effort
(slow/irregular = 1 point), Muscle tone (flaccid = 0 points), Reflex irritability (no response
= 0 points), and Color (acrocyanosis = 1 point). The sum is 3. A score of 3 indicates
significant distress requiring immediate resuscitation.
Question 4: A client at 10 weeks of gestation asks the nurse about dietary sources
of folic acid to prevent neural tube defects. Which food should the nurse
recommend?
A. Red meat
B. Fortified cereals
C. Milk products
D. Citrus fruits
CORRECT ANSWER: B. Fortified cereals
Rationale: Folic acid (folate) is crucial for preventing neural tube defects. While citrus
fruits and leafy greens contain natural folate, fortified cereals and grains are among the
richest and most reliable sources of synthetic folic acid recommended for pregnant
women. Red meat is high in iron, and milk products are high in calcium.
Question 5: A nurse is teaching a client about the signs of preeclampsia. Which
statement by the client indicates a need for further teaching?
A. "I should call the doctor if I have a severe headache."
B. "Swelling in my face and hands is a warning sign."
,C. "I will monitor my weight gain weekly."
D. "Increased energy levels are a symptom I should watch for."
CORRECT ANSWER: D. "Increased energy levels are a symptom I should watch for."
Rationale: Symptoms of preeclampsia include severe headache, visual disturbances,
epigastric pain, and sudden edema of the face and hands. Increased energy is not a
symptom; rather, patients often feel unwell. Recognizing that increased energy is not a
sign indicates the client needs correction if they think it is a warning sign, or if the
statement implies they believe it is a symptom, it shows a misunderstanding. The
question asks for a statement indicating a need for further teaching. If the client says
"Increased energy levels are a symptom," that is false, so they need teaching.
Question 6: A newborn born to a diabetic mother is at highest risk for which
condition immediately after birth?
A. Hyperglycemia
B. Hypoglycemia
C. Hypercalcemia
D. Hypobilirubinemia
CORRECT ANSWER: B. Hypoglycemia
Rationale: Infants of diabetic mothers (IDM) are exposed to high maternal glucose levels
in utero, leading to fetal hyperinsulinemia. Upon birth, the maternal glucose supply is
cut off, but the infant's insulin levels remain high, causing rapid depletion of blood
glucose (hypoglycemia). They are also at risk for hypocalcemia and hyperbilirubinemia,
but hypoglycemia is the most immediate and common metabolic risk.
Question 7: A client receiving magnesium sulfate for severe preeclampsia has a
respiratory rate of 10/min and absent deep tendon reflexes. What is the priority
action by the nurse?
A. Administer a bolus of magnesium sulfate
B. Check the blood pressure
C. Stop the magnesium sulfate infusion
D. Encourage the client to deep breathe
CORRECT ANSWER: C. Stop the magnesium sulfate infusion
Rationale: Signs of magnesium toxicity include respiratory depression (<12/min), absent
deep tendon reflexes, and oliguria. The priority action is to stop the infusion
immediately to prevent respiratory arrest. Calcium gluconate should be available as an
antidote. Checking BP is important but secondary to stopping the toxic agent.
Question 8: During a prenatal visit, a client at 20 weeks gestation reports feeling
fluttering sensations in her abdomen. How should the nurse document this
finding?
, A. Lightening
B. Ballottement
C. Quickening
D. Engagement
CORRECT ANSWER: C. Quickening
Rationale: Quickening is the term used to describe the mother's first perception of fetal
movement, typically occurring between 16 and 20 weeks of gestation. Lightening refers
to the fetus dropping into the pelvis. Ballottement is a passive fetal movement felt
during examination. Engagement is the entry of the fetal presenting part into the pelvic
inlet.
Question 9: A nurse is caring for a client with hyperemesis gravidarum. Which
laboratory value should the nurse monitor closely?
A. Serum potassium
B. Urine ketones
C. Hemoglobin
D. White blood cell count
CORRECT ANSWER: B. Urine ketones
Rationale: Hyperemesis gravidarum involves severe nausea and vomiting leading to
dehydration and starvation. The body breaks down fat stores for energy, resulting in the
production of ketones, which appear in the urine (ketonuria). While electrolyte
imbalances like hypokalemia are also concerns, ketonuria is a direct indicator of the
severity of starvation and dehydration in this context.
Question 10: A client in labor requests a non-pharmacological method to relieve
back pain caused by a fetus in the occiput posterior position. Which technique
should the nurse suggest?
A. Effleurage
B. Counterpressure
C. Guided imagery
D. Biofeedback
CORRECT ANSWER: B. Counterpressure
Rationale: Back labor, often associated with the occiput posterior (OP) position, causes
intense lower back pain. Applying counterpressure (firm pressure) to the sacral area
helps alleviate this specific type of pain. Effleurage is light stroking, guided imagery and
biofeedback are cognitive techniques, which are helpful but less specific for
mechanical back pain than counterpressure.
Question 11: A newborn is noted to have a Moro reflex. How should the nurse elicit
this reflex?
