Maternal-Newborn
Nursing and Women's
Health (Part 3)
### Question 1
A patient at 39 weeks gestation is in active labor. The nurse notes variable decelerations on the fetal
heart rate tracing. Which action should the nurse take first?
A. Change the patient's position
B. Administer oxygen via non-rebreather mask
C. Increase the intravenous fluid rate
D. Notify the healthcare provider
,💫RATIONALE✔️✔️: Variable decelerations are typically caused by cord compression. The first
intervention is to change the patient's position (usually to the side-lying position) to relieve pressure on
the umbilical cord. If the decelerations persist, the nurse should then administer oxygen and increase IV
fluids.
💫ANSWER✔️✔️: A. Change the patient's position
---
### Question 2
A postpartum patient is diagnosed with endometritis. Which finding is most consistent with this
condition?
A. Breast engorgement and mastitis
B. Uterine tenderness and fever
C. Urinary frequency and dysuria
D. Incisional pain and erythema
💫RATIONALE✔️✔️: Endometritis is an infection of the endometrium (uterine lining) characterized by
uterine tenderness, fever, and foul-smelling lochia. It is more common after cesarean delivery.
Treatment includes antibiotics and supportive care.
💫ANSWER✔️✔️: B. Uterine tenderness and fever
---
,### Question 3
The nurse is assessing a patient in the first trimester of pregnancy. Which finding is considered a normal
physiological change of pregnancy?
A. Decreased heart rate
B. Increased blood pressure
C. Nausea and vomiting
D. Decreased respiratory rate
💫RATIONALE✔️✔️: Nausea and vomiting are common in the first trimester, often referred to as
morning sickness. Heart rate increases by 10-15 beats per minute, blood pressure decreases slightly due
to vasodilation, and respiratory rate may increase slightly.
💫ANSWER✔️✔️: C. Nausea and vomiting
---
### Question 4
A patient with preeclampsia is receiving magnesium sulfate. Which finding indicates magnesium
toxicity?
A. Deep tendon reflexes 2+
B. Respiratory rate of 16 breaths per minute
C. Urinary output of 25 mL per hour
D. Serum magnesium level of 8 mEq/L
, 💫RATIONALE✔️✔️: A serum magnesium level of 8 mEq/L is above the therapeutic range (4-7 mEq/L)
and indicates magnesium toxicity. Signs include loss of deep tendon reflexes (hyporeflexia), respiratory
depression (< 12 breaths/min), and oliguria (< 30 mL/hour). The antidote is calcium gluconate.
💫ANSWER✔️✔️: D. Serum magnesium level of 8 mEq/L
---
### Question 5
A nurse is providing discharge teaching to a postpartum patient about breastfeeding. Which instruction
should the nurse include?
A. "Wash your nipples with soap and water before each feeding."
B. "Breastfeed on demand, at least 8-12 times in 24 hours."
C. "Supplement with formula if the baby seems hungry."
D. "Limit feeding time to 5 minutes on each breast."
💫RATIONALE✔️✔️: Breastfeeding on demand, at least 8-12 times in 24 hours, helps establish milk
supply and ensures adequate infant nutrition. Nipples should be cleansed with water only, not soap, to
prevent drying and cracking.
💫ANSWER✔️✔️: B. "Breastfeed on demand, at least 8-12 times in 24 hours."
---
Nursing and Women's
Health (Part 3)
### Question 1
A patient at 39 weeks gestation is in active labor. The nurse notes variable decelerations on the fetal
heart rate tracing. Which action should the nurse take first?
A. Change the patient's position
B. Administer oxygen via non-rebreather mask
C. Increase the intravenous fluid rate
D. Notify the healthcare provider
,💫RATIONALE✔️✔️: Variable decelerations are typically caused by cord compression. The first
intervention is to change the patient's position (usually to the side-lying position) to relieve pressure on
the umbilical cord. If the decelerations persist, the nurse should then administer oxygen and increase IV
fluids.
💫ANSWER✔️✔️: A. Change the patient's position
---
### Question 2
A postpartum patient is diagnosed with endometritis. Which finding is most consistent with this
condition?
A. Breast engorgement and mastitis
B. Uterine tenderness and fever
C. Urinary frequency and dysuria
D. Incisional pain and erythema
💫RATIONALE✔️✔️: Endometritis is an infection of the endometrium (uterine lining) characterized by
uterine tenderness, fever, and foul-smelling lochia. It is more common after cesarean delivery.
Treatment includes antibiotics and supportive care.
💫ANSWER✔️✔️: B. Uterine tenderness and fever
---
,### Question 3
The nurse is assessing a patient in the first trimester of pregnancy. Which finding is considered a normal
physiological change of pregnancy?
A. Decreased heart rate
B. Increased blood pressure
C. Nausea and vomiting
D. Decreased respiratory rate
💫RATIONALE✔️✔️: Nausea and vomiting are common in the first trimester, often referred to as
morning sickness. Heart rate increases by 10-15 beats per minute, blood pressure decreases slightly due
to vasodilation, and respiratory rate may increase slightly.
💫ANSWER✔️✔️: C. Nausea and vomiting
---
### Question 4
A patient with preeclampsia is receiving magnesium sulfate. Which finding indicates magnesium
toxicity?
A. Deep tendon reflexes 2+
B. Respiratory rate of 16 breaths per minute
C. Urinary output of 25 mL per hour
D. Serum magnesium level of 8 mEq/L
, 💫RATIONALE✔️✔️: A serum magnesium level of 8 mEq/L is above the therapeutic range (4-7 mEq/L)
and indicates magnesium toxicity. Signs include loss of deep tendon reflexes (hyporeflexia), respiratory
depression (< 12 breaths/min), and oliguria (< 30 mL/hour). The antidote is calcium gluconate.
💫ANSWER✔️✔️: D. Serum magnesium level of 8 mEq/L
---
### Question 5
A nurse is providing discharge teaching to a postpartum patient about breastfeeding. Which instruction
should the nurse include?
A. "Wash your nipples with soap and water before each feeding."
B. "Breastfeed on demand, at least 8-12 times in 24 hours."
C. "Supplement with formula if the baby seems hungry."
D. "Limit feeding time to 5 minutes on each breast."
💫RATIONALE✔️✔️: Breastfeeding on demand, at least 8-12 times in 24 hours, helps establish milk
supply and ensures adequate infant nutrition. Nipples should be cleansed with water only, not soap, to
prevent drying and cracking.
💫ANSWER✔️✔️: B. "Breastfeed on demand, at least 8-12 times in 24 hours."
---
