BSN366 Exam 4 Actual Exam Style V3 | BSN 366
HESI RN Exit | Nightingale COMPREHENSIVE
MATERNAL-NEWBORN NURSING EXAMINATION
Practice Questions with Answers and Rationales
SECTION 1: INTRAPARTUM CARE AND LABOR MANAGEMENT (Questions
1-50)
1. A nurse is caring for a client in labor who is receiving oxytocin. The
nurse notes late decelerations on the fetal monitor. What is the priority
nursing action?
A) Reposition the client to the lateral position
B) Increase the oxytocin infusion rate
C) Document the findings as normal labor progress
D) Prepare for an immediate vaginal delivery
Rationale: Late decelerations are indicative of uteroplacental insufficiency
and require immediate intervention to improve oxygenation. Repositioning
the mother to the lateral position relieves pressure on the vena cava and
increases blood flow to the uterus. The nurse should also stop the oxytocin
and notify the provider.
2. A postpartum nurse is assessing a client 2 hours after delivery. The
fundus is displaced to the right. Which action should the nurse take first?
A) Massage the fundus vigorously
B) Assist the client to empty her bladder
C) Administer oxytocin as prescribed
D) Notify the healthcare provider immediately
Rationale: A fundus displaced to the right and boggy usually indicates a full
bladder, which prevents the uterus from contracting effectively. Assisting the
client to void allows the uterus to return to the midline and contract
,effectively. If the fundus remains boggy after voiding, massage and
medications would be the next steps.
3. Which clinical finding should the nurse report immediately for a
newborn who is 12 hours old?
A) Milia across the bridge of the nose
B) Acrocyanosis in the hands and feet
C) Passing of the first meconium stool
D) Jaundice appearing on the face and chest
Rationale: Jaundice appearing within the first 24 hours of life is considered
pathological and requires immediate investigation for hemolytic disease.
Acrocyanosis is a normal finding in the first 24-48 hours post-birth. Milia and
meconium passage are normal newborn findings.
4. The nurse is assessing a client in active labor. The cervix is 6 cm
dilated, 90% effaced, and the fetal head is at 0 station. The nurse should
recognize that the client is in which phase of labor?
A) Latent phase
B) Active phase
C) Transition phase
D) Second stage
Rationale: The active phase of the first stage of labor is characterized by
cervical dilation from 4-7 cm. The transition phase is 8-10 cm. The client is in
the active phase.
5. A client who is 38 weeks gestation is admitted with premature rupture
of membranes (PROM). Which assessment finding is most concerning?
A) Fetal heart rate of 145 bpm
B) Foul-smelling amniotic fluid
C) Maternal temperature of 98.8°F (37.1°C)
D) Clear amniotic fluid
,Rationale: Foul-smelling amniotic fluid may indicate chorioamnionitis, an
infection that can affect both mother and fetus. FHR of 145 bpm and clear fluid
are normal findings. A temperature of 98.8°F is within normal range.
6. The nurse is caring for a client receiving magnesium sulfate for
preeclampsia. Which assessment finding indicates magnesium toxicity?
A) Loss of deep tendon reflexes
B) Blood pressure of 150/92 mmHg
C) Urine output of 40 ml/hr
D) Respiratory rate of 18 breaths/min
Rationale: Loss of deep tendon reflexes is a sign of magnesium toxicity. Other
signs include respiratory depression (< 12 breaths/min), oliguria (< 30
ml/hr), and cardiac arrest.
7. The nurse is assessing fetal heart rate (FHR) during labor. Which
pattern is most concerning?
A) Late decelerations
B) Early decelerations
C) Moderate variability
D) Accelerations
Rationale: Late decelerations indicate uteroplacental insufficiency and are a
non-reassuring pattern requiring immediate intervention. Early decelerations
are benign; moderate variability and accelerations are reassuring findings.
8. A client in labor at 40 weeks gestation has an order for an epidural.
Which assessment should the nurse perform immediately before the
epidural is placed?
A) Fetal heart rate
B) Blood pressure
C) Contraction frequency
D) Cervical dilation
, Rationale: Blood pressure should be assessed before epidural placement to
establish a baseline and monitor for hypotension, a common side effect of
epidural anesthesia.
9. A client is 9 cm dilated and reports a strong urge to push. The nurse
should:
A) Instruct the client to blow through the urge to push
B) Encourage the client to push with each contraction
C) Prepare for immediate delivery
D) Notify the healthcare provider
Rationale: Pushing before complete cervical dilation (10 cm) can cause
cervical edema and injury. The client should be instructed to blow through the
urge to push until the cervix is fully dilated.
10. The nurse is evaluating the effectiveness of oxytocin (Pitocin)
infusion. Which finding indicates a therapeutic response?
A) Effective uterine contractions every 2-3 minutes
B) Decreased fetal heart rate
C) Maternal hypertension
D) Cervical dilation of 2 cm
Rationale: Oxytocin is given to stimulate uterine contractions. Effective
contractions every 2-3 minutes indicate a therapeutic response.
11. A client with a history of cesarean delivery is attempting a VBAC.
Which finding indicates the greatest risk for uterine rupture?
A) Fetal heart rate decelerations and abdominal pain
B) Maternal fever
C) Meconium-stained amniotic fluid
D) Maternal hypertension
Rationale: Fetal heart rate decelerations and sudden, severe abdominal pain
are signs of uterine rupture, a life-threatening emergency.
HESI RN Exit | Nightingale COMPREHENSIVE
MATERNAL-NEWBORN NURSING EXAMINATION
Practice Questions with Answers and Rationales
SECTION 1: INTRAPARTUM CARE AND LABOR MANAGEMENT (Questions
1-50)
1. A nurse is caring for a client in labor who is receiving oxytocin. The
nurse notes late decelerations on the fetal monitor. What is the priority
nursing action?
A) Reposition the client to the lateral position
B) Increase the oxytocin infusion rate
C) Document the findings as normal labor progress
D) Prepare for an immediate vaginal delivery
Rationale: Late decelerations are indicative of uteroplacental insufficiency
and require immediate intervention to improve oxygenation. Repositioning
the mother to the lateral position relieves pressure on the vena cava and
increases blood flow to the uterus. The nurse should also stop the oxytocin
and notify the provider.
2. A postpartum nurse is assessing a client 2 hours after delivery. The
fundus is displaced to the right. Which action should the nurse take first?
A) Massage the fundus vigorously
B) Assist the client to empty her bladder
C) Administer oxytocin as prescribed
D) Notify the healthcare provider immediately
Rationale: A fundus displaced to the right and boggy usually indicates a full
bladder, which prevents the uterus from contracting effectively. Assisting the
client to void allows the uterus to return to the midline and contract
,effectively. If the fundus remains boggy after voiding, massage and
medications would be the next steps.
3. Which clinical finding should the nurse report immediately for a
newborn who is 12 hours old?
A) Milia across the bridge of the nose
B) Acrocyanosis in the hands and feet
C) Passing of the first meconium stool
D) Jaundice appearing on the face and chest
Rationale: Jaundice appearing within the first 24 hours of life is considered
pathological and requires immediate investigation for hemolytic disease.
Acrocyanosis is a normal finding in the first 24-48 hours post-birth. Milia and
meconium passage are normal newborn findings.
4. The nurse is assessing a client in active labor. The cervix is 6 cm
dilated, 90% effaced, and the fetal head is at 0 station. The nurse should
recognize that the client is in which phase of labor?
A) Latent phase
B) Active phase
C) Transition phase
D) Second stage
Rationale: The active phase of the first stage of labor is characterized by
cervical dilation from 4-7 cm. The transition phase is 8-10 cm. The client is in
the active phase.
5. A client who is 38 weeks gestation is admitted with premature rupture
of membranes (PROM). Which assessment finding is most concerning?
A) Fetal heart rate of 145 bpm
B) Foul-smelling amniotic fluid
C) Maternal temperature of 98.8°F (37.1°C)
D) Clear amniotic fluid
,Rationale: Foul-smelling amniotic fluid may indicate chorioamnionitis, an
infection that can affect both mother and fetus. FHR of 145 bpm and clear fluid
are normal findings. A temperature of 98.8°F is within normal range.
6. The nurse is caring for a client receiving magnesium sulfate for
preeclampsia. Which assessment finding indicates magnesium toxicity?
A) Loss of deep tendon reflexes
B) Blood pressure of 150/92 mmHg
C) Urine output of 40 ml/hr
D) Respiratory rate of 18 breaths/min
Rationale: Loss of deep tendon reflexes is a sign of magnesium toxicity. Other
signs include respiratory depression (< 12 breaths/min), oliguria (< 30
ml/hr), and cardiac arrest.
7. The nurse is assessing fetal heart rate (FHR) during labor. Which
pattern is most concerning?
A) Late decelerations
B) Early decelerations
C) Moderate variability
D) Accelerations
Rationale: Late decelerations indicate uteroplacental insufficiency and are a
non-reassuring pattern requiring immediate intervention. Early decelerations
are benign; moderate variability and accelerations are reassuring findings.
8. A client in labor at 40 weeks gestation has an order for an epidural.
Which assessment should the nurse perform immediately before the
epidural is placed?
A) Fetal heart rate
B) Blood pressure
C) Contraction frequency
D) Cervical dilation
, Rationale: Blood pressure should be assessed before epidural placement to
establish a baseline and monitor for hypotension, a common side effect of
epidural anesthesia.
9. A client is 9 cm dilated and reports a strong urge to push. The nurse
should:
A) Instruct the client to blow through the urge to push
B) Encourage the client to push with each contraction
C) Prepare for immediate delivery
D) Notify the healthcare provider
Rationale: Pushing before complete cervical dilation (10 cm) can cause
cervical edema and injury. The client should be instructed to blow through the
urge to push until the cervix is fully dilated.
10. The nurse is evaluating the effectiveness of oxytocin (Pitocin)
infusion. Which finding indicates a therapeutic response?
A) Effective uterine contractions every 2-3 minutes
B) Decreased fetal heart rate
C) Maternal hypertension
D) Cervical dilation of 2 cm
Rationale: Oxytocin is given to stimulate uterine contractions. Effective
contractions every 2-3 minutes indicate a therapeutic response.
11. A client with a history of cesarean delivery is attempting a VBAC.
Which finding indicates the greatest risk for uterine rupture?
A) Fetal heart rate decelerations and abdominal pain
B) Maternal fever
C) Meconium-stained amniotic fluid
D) Maternal hypertension
Rationale: Fetal heart rate decelerations and sudden, severe abdominal pain
are signs of uterine rupture, a life-threatening emergency.
