NCLEX RN Maternal Newborn
Nursing Exam 3 Questions And
Correct Answers (Verified Answers)
Plus Rationales 2026 Q&A | Instant
Download Pdf
1. A 34-year-old primigravida at 38 weeks gestation presents to the labor and delivery
unit with complaints of a sudden gush of fluid from the vagina, followed by continuous
trickling. She denies contractions. The nurse performs a sterile speculum examination
and observes pooling of clear fluid in the posterior vaginal vault. Nitrazine paper turns
dark blue, and ferning is noted under the microscope. The fetal heart rate is 145 beats
per minute with moderate variability. The client's vital signs are stable. Which action
should the nurse take FIRST?
A) Administer a bolus of intravenous fluids
B) Perform a digital cervical examination to assess dilation and effacement
C) Obtain a sterile speculum examination to confirm the presence of prolapsed cord
D) Initiate continuous fetal monitoring and notify the healthcare provider
Rationale: The correct action is to initiate continuous fetal monitoring and notify
the healthcare provider. The client has experienced premature rupture of
membranes (PROM) confirmed by the positive ferning and Nitrazine tests. The
priority is to assess fetal well-being through continuous monitoring and notify the
provider for further orders. The other options are incorrect because administering
IV fluids is not the immediate priority, performing a digital cervical examination is
contraindicated in the presence of ruptured membranes due to the risk of
introducing infection, and a prolapsed cord assessment can be performed using a
sterile speculum but the nurse must first initiate monitoring and notify the
provider.
,2. A nurse is caring for a client who is 6 hours postpartum after a vaginal delivery of a
4,200-gram infant. The client's fundus is noted to be boggy, displaced to the right, and
located two fingerbreadths above the umbilicus. The perineal pad is saturated with
lochia rubra containing large clots. The client's blood pressure is 100/62 mmHg, heart
rate is 110 beats per minute, and respiratory rate is 22 breaths per minute. Which action
should the nurse implement FIRST?
A) Administer oxytocin 20 units in 1,000 mL of lactated Ringer's solution as prescribed
B) Assess the client's pain level and provide prescribed analgesics
C) Assist the client to empty her bladder and reassess fundal position and tone
D) Document the findings and continue to monitor every 15 minutes
Rationale: The correct action is to assist the client to empty her bladder and
reassess fundal position and tone. A boggy uterus displaced to the right indicates a
full bladder, which prevents effective uterine contraction and leads to hemorrhage.
Emptying the bladder often resolves uterine atony and allows the fundus to
contract effectively. The other options are incorrect because administering oxytocin
would be appropriate after ensuring the bladder is empty, assessing pain is not the
priority, and documentation alone would delay necessary intervention.
3. A client at 32 weeks gestation is admitted with preterm labor. The healthcare provider
prescribes betamethasone 12 mg intramuscularly every 24 hours for two doses. The
client asks the nurse about the purpose of this medication. Which response by the nurse
is MOST appropriate?
A) "This medication will stop your contractions and prevent preterm delivery"
B) "The medication will help to prevent infection in your baby after delivery"
C) "This drug is given to help your baby's lungs mature faster"
D) "Betamethasone accelerates fetal lung maturation and reduces the risk of
respiratory distress syndrome in preterm infants"
Rationale: The correct response is that betamethasone accelerates fetal lung
maturation and reduces the risk of respiratory distress syndrome in preterm
infants. Corticosteroids like betamethasone cross the placenta and stimulate
surfactant production in the fetal lungs. The other options are incorrect because
betamethasone does not stop uterine contractions, does not prevent neonatal
infections, and while it does help the baby's lungs mature, the most comprehensive
,and accurate response addresses the specific reduction in respiratory distress
syndrome risk.
4. A nurse is assessing a newborn who is 12 hours old. The newborn has a heart rate of
160 beats per minute, respiratory rate of 56 breaths per minute with mild grunting, and
an axillary temperature of 36.2°C (97.2°F). The newborn's skin is mottled with
acrocyanosis. Which nursing intervention is the HIGHEST priority?
A) Administer supplemental oxygen via hood
B) Place the newborn under a radiant warmer
C) Notify the healthcare provider immediately
D) Obtain a blood glucose level
Rationale: The correct intervention is to place the newborn under a radiant
warmer. The newborn is exhibiting signs of cold stress, including a low axillary
temperature of 36.2°C, mottled skin, and acrocyanosis. Cold stress can lead to
increased oxygen consumption, respiratory distress, and metabolic acidosis. The
priority is to rewarm the infant. The other options are incorrect because while
supplemental oxygen may be needed, rewarming is the priority, notifying the
provider can occur after implementing warming measures, and obtaining a blood
glucose level is important but secondary to immediate thermal regulation.
5. A client at 40 weeks gestation is in active labor. The nurse notes a late deceleration on
the fetal monitor tracing that reaches 80 beats per minute and lasts for 45 seconds.
Which action should the nurse take FIRST?
A) Increase the rate of the oxytocin infusion
B) Position the client on her left side
C) Administer oxygen via face mask at 10 L/min
D) Prepare for an immediate cesarean delivery
Rationale: The correct action is to position the client on her left side. Late
decelerations indicate uteroplacental insufficiency, and positioning the client on
her side relieves compression of the vena cava, improves venous return, and
increases uterine blood flow. The other options are incorrect because increasing
, oxytocin would worsen uterine contractions and further compromise fetal
oxygenation, administering oxygen is appropriate but should occur after
repositioning, and preparing for immediate cesarean delivery would be premature
without first attempting corrective measures.
6. A postpartum client who delivered 24 hours ago reports severe pain and burning
upon urination. The nurse notes that the client's perineum is edematous with an
episiotomy that appears approximated with mild erythema. The client's temperature is
37.8°C (100.0°F). Which nursing action is MOST appropriate?
A) Apply ice packs to the perineal area
B) Administer prescribed oral antibiotics
C) Instruct the client to increase oral fluid intake and encourage frequent voiding
D) Obtain a clean-catch urine specimen for culture and sensitivity
Rationale: The correct action is to instruct the client to increase oral fluid intake
and encourage frequent voiding. The client's symptoms of pain and burning upon
urination, along with elevated temperature, suggest a possible urinary tract
infection (UTI). Increasing fluid intake helps dilute urine and flush bacteria from
the urinary tract. The other options are incorrect because ice packs address
perineal discomfort but not the urinary symptoms, antibiotics should not be
administered without a confirmed diagnosis, and while a urine culture may be
needed, the immediate action should be to increase fluid intake and encourage
voiding.
7. A nurse is providing education to a group of pregnant clients about the signs and
symptoms of preeclampsia. Which statement by a client indicates a correct
understanding of the teaching?
A) "I will need to monitor my blood pressure at home and report readings above 130/80
mmHg"
B) "I should report any swelling in my ankles and feet to my healthcare provider"
C) "I need to report sudden weight gain of more than 2 pounds in one week,
especially if accompanied by headaches or visual disturbances"
D) "I will take low-dose aspirin every day to prevent preeclampsia from developing"
Nursing Exam 3 Questions And
Correct Answers (Verified Answers)
Plus Rationales 2026 Q&A | Instant
Download Pdf
1. A 34-year-old primigravida at 38 weeks gestation presents to the labor and delivery
unit with complaints of a sudden gush of fluid from the vagina, followed by continuous
trickling. She denies contractions. The nurse performs a sterile speculum examination
and observes pooling of clear fluid in the posterior vaginal vault. Nitrazine paper turns
dark blue, and ferning is noted under the microscope. The fetal heart rate is 145 beats
per minute with moderate variability. The client's vital signs are stable. Which action
should the nurse take FIRST?
A) Administer a bolus of intravenous fluids
B) Perform a digital cervical examination to assess dilation and effacement
C) Obtain a sterile speculum examination to confirm the presence of prolapsed cord
D) Initiate continuous fetal monitoring and notify the healthcare provider
Rationale: The correct action is to initiate continuous fetal monitoring and notify
the healthcare provider. The client has experienced premature rupture of
membranes (PROM) confirmed by the positive ferning and Nitrazine tests. The
priority is to assess fetal well-being through continuous monitoring and notify the
provider for further orders. The other options are incorrect because administering
IV fluids is not the immediate priority, performing a digital cervical examination is
contraindicated in the presence of ruptured membranes due to the risk of
introducing infection, and a prolapsed cord assessment can be performed using a
sterile speculum but the nurse must first initiate monitoring and notify the
provider.
,2. A nurse is caring for a client who is 6 hours postpartum after a vaginal delivery of a
4,200-gram infant. The client's fundus is noted to be boggy, displaced to the right, and
located two fingerbreadths above the umbilicus. The perineal pad is saturated with
lochia rubra containing large clots. The client's blood pressure is 100/62 mmHg, heart
rate is 110 beats per minute, and respiratory rate is 22 breaths per minute. Which action
should the nurse implement FIRST?
A) Administer oxytocin 20 units in 1,000 mL of lactated Ringer's solution as prescribed
B) Assess the client's pain level and provide prescribed analgesics
C) Assist the client to empty her bladder and reassess fundal position and tone
D) Document the findings and continue to monitor every 15 minutes
Rationale: The correct action is to assist the client to empty her bladder and
reassess fundal position and tone. A boggy uterus displaced to the right indicates a
full bladder, which prevents effective uterine contraction and leads to hemorrhage.
Emptying the bladder often resolves uterine atony and allows the fundus to
contract effectively. The other options are incorrect because administering oxytocin
would be appropriate after ensuring the bladder is empty, assessing pain is not the
priority, and documentation alone would delay necessary intervention.
3. A client at 32 weeks gestation is admitted with preterm labor. The healthcare provider
prescribes betamethasone 12 mg intramuscularly every 24 hours for two doses. The
client asks the nurse about the purpose of this medication. Which response by the nurse
is MOST appropriate?
A) "This medication will stop your contractions and prevent preterm delivery"
B) "The medication will help to prevent infection in your baby after delivery"
C) "This drug is given to help your baby's lungs mature faster"
D) "Betamethasone accelerates fetal lung maturation and reduces the risk of
respiratory distress syndrome in preterm infants"
Rationale: The correct response is that betamethasone accelerates fetal lung
maturation and reduces the risk of respiratory distress syndrome in preterm
infants. Corticosteroids like betamethasone cross the placenta and stimulate
surfactant production in the fetal lungs. The other options are incorrect because
betamethasone does not stop uterine contractions, does not prevent neonatal
infections, and while it does help the baby's lungs mature, the most comprehensive
,and accurate response addresses the specific reduction in respiratory distress
syndrome risk.
4. A nurse is assessing a newborn who is 12 hours old. The newborn has a heart rate of
160 beats per minute, respiratory rate of 56 breaths per minute with mild grunting, and
an axillary temperature of 36.2°C (97.2°F). The newborn's skin is mottled with
acrocyanosis. Which nursing intervention is the HIGHEST priority?
A) Administer supplemental oxygen via hood
B) Place the newborn under a radiant warmer
C) Notify the healthcare provider immediately
D) Obtain a blood glucose level
Rationale: The correct intervention is to place the newborn under a radiant
warmer. The newborn is exhibiting signs of cold stress, including a low axillary
temperature of 36.2°C, mottled skin, and acrocyanosis. Cold stress can lead to
increased oxygen consumption, respiratory distress, and metabolic acidosis. The
priority is to rewarm the infant. The other options are incorrect because while
supplemental oxygen may be needed, rewarming is the priority, notifying the
provider can occur after implementing warming measures, and obtaining a blood
glucose level is important but secondary to immediate thermal regulation.
5. A client at 40 weeks gestation is in active labor. The nurse notes a late deceleration on
the fetal monitor tracing that reaches 80 beats per minute and lasts for 45 seconds.
Which action should the nurse take FIRST?
A) Increase the rate of the oxytocin infusion
B) Position the client on her left side
C) Administer oxygen via face mask at 10 L/min
D) Prepare for an immediate cesarean delivery
Rationale: The correct action is to position the client on her left side. Late
decelerations indicate uteroplacental insufficiency, and positioning the client on
her side relieves compression of the vena cava, improves venous return, and
increases uterine blood flow. The other options are incorrect because increasing
, oxytocin would worsen uterine contractions and further compromise fetal
oxygenation, administering oxygen is appropriate but should occur after
repositioning, and preparing for immediate cesarean delivery would be premature
without first attempting corrective measures.
6. A postpartum client who delivered 24 hours ago reports severe pain and burning
upon urination. The nurse notes that the client's perineum is edematous with an
episiotomy that appears approximated with mild erythema. The client's temperature is
37.8°C (100.0°F). Which nursing action is MOST appropriate?
A) Apply ice packs to the perineal area
B) Administer prescribed oral antibiotics
C) Instruct the client to increase oral fluid intake and encourage frequent voiding
D) Obtain a clean-catch urine specimen for culture and sensitivity
Rationale: The correct action is to instruct the client to increase oral fluid intake
and encourage frequent voiding. The client's symptoms of pain and burning upon
urination, along with elevated temperature, suggest a possible urinary tract
infection (UTI). Increasing fluid intake helps dilute urine and flush bacteria from
the urinary tract. The other options are incorrect because ice packs address
perineal discomfort but not the urinary symptoms, antibiotics should not be
administered without a confirmed diagnosis, and while a urine culture may be
needed, the immediate action should be to increase fluid intake and encourage
voiding.
7. A nurse is providing education to a group of pregnant clients about the signs and
symptoms of preeclampsia. Which statement by a client indicates a correct
understanding of the teaching?
A) "I will need to monitor my blood pressure at home and report readings above 130/80
mmHg"
B) "I should report any swelling in my ankles and feet to my healthcare provider"
C) "I need to report sudden weight gain of more than 2 pounds in one week,
especially if accompanied by headaches or visual disturbances"
D) "I will take low-dose aspirin every day to prevent preeclampsia from developing"
