NCLEX RN Maternal Newborn Nursing
Exam 2 Questions And Correct Answers
(Verified Answers) Plus Rationales 2026
Q&A | Instant Download Pdf
1. A nurse is caring for a primigravida client at 34 weeks' gestation who reports
sudden onset of painless, bright red vaginal bleeding. The client's vital signs are
blood pressure 110/68 mm Hg, heart rate 92 bpm, respiratory rate 18/min, and
temperature 37.1°C. The fetal heart rate is 145 bpm with moderate variability.
Which action should the nurse take first?
A. Perform a sterile vaginal examination to assess cervical dilation
B. Place the client in a side-lying position and initiate continuous electronic fetal
monitoring
C. Administer betamethasone 12 mg intramuscularly
D. Prepare the client for an immediate cesarean delivery
Rationale: Painless, bright red vaginal bleeding in the third trimester is a classic
sign of placenta previa. Vaginal examination is contraindicated because it can
disrupt the placenta and cause massive hemorrhage. The nurse should first place
the client in a side-lying position to optimize uterine blood flow and initiate
continuous fetal monitoring to assess fetal well-being. Betamethasone may be
indicated if preterm delivery is anticipated, but it is not the first action. Cesarean
delivery is not the first action without further assessment.
2. A nurse is assessing a newborn who is 12 hours old. The newborn's respiratory
rate is 68 breaths/min with intermittent periods of apnea lasting 10 seconds. The
,nurse notes nasal flaring and grunting. Which intervention should the nurse
implement?
A. Continue to monitor the newborn closely because these findings are normal
B. Notify the healthcare provider immediately because these findings indicate
respiratory distress
C. Place the newborn in a prone position to improve oxygenation
D. Administer oxygen via nasal cannula at 2 L/min
Rationale: Normal newborn respiratory rate ranges from 30 to 60 breaths/min.
Periods of apnea lasting less than 15 seconds without color change are normal.
However, nasal flaring and grunting are signs of respiratory distress and require
immediate notification of the healthcare provider. Placing the newborn prone is
unsafe and increases the risk of SIDS. Supplemental oxygen should only be
administered with a provider's order and under careful monitoring.
3. A postpartum client who delivered 48 hours ago reports breast engorgement,
bilateral breast warmth, and tenderness. The client is breastfeeding her newborn.
Which instruction should the nurse provide?
A. Apply ice packs to the breasts for 20 minutes before each feeding
B. Restrict fluid intake to reduce breast milk production
C. Apply warm compresses and gently massage the breasts before feeding
D. Wear a tight-fitting bra continuously to suppress milk production
Rationale: Breast engorgement is caused by vascular congestion and milk
accumulation. Warm compresses and gentle massage before feeding help
stimulate the let-down reflex and facilitate milk flow, relieving engorgement. Ice
packs are applied after feeding to reduce swelling and discomfort, not before.
Fluid restriction is inappropriate and can lead to dehydration. Tight bras can
worsen engorgement and increase the risk of mastitis by obstructing milk flow.
,4. A nurse is reviewing the laboratory results of a client at 28 weeks' gestation.
The client's 1-hour glucose tolerance test result is 155 mg/dL. Which action should
the nurse anticipate?
A. Instruct the client to begin a 1,200-calorie diabetic diet
B. Schedule the client for a 3-hour oral glucose tolerance test
C. Diagnose the client with gestational diabetes mellitus
D. Repeat the 1-hour glucose tolerance test in 4 weeks
Rationale: A 1-hour glucose tolerance test result of 155 mg/dL is elevated (normal
is less than 140 mg/dL). This indicates a need for further testing. The 3-hour oral
glucose tolerance test is the diagnostic test for gestational diabetes. A diagnosis of
gestational diabetes is not made based solely on the 1-hour screening test.
Repeating the test in 4 weeks would delay diagnosis and management.
5. A nurse is performing an assessment on a client who is 6 hours postpartum
following a vaginal delivery. The nurse notes a firm fundus at the umbilicus,
moderate lochia rubra, and a perineal pad that is saturated with blood in 15
minutes. Which action should the nurse take first?
A. Document the findings as normal
B. Increase the rate of intravenous fluids
C. Massage the fundus and assess for bladder distension
D. Administer methylergonovine 0.2 mg intramuscularly
Rationale: A saturated perineal pad in 15 minutes indicates excessive bleeding.
The nurse should first massage the fundus to ensure it is firm and assess for
bladder distension, which can cause uterine atony and bleeding. If the fundus is
firm and bleeding continues, further interventions such as administering
uterotonics may be indicated. Documentation is important but not the first action.
Increasing IV fluids is a supportive measure but does not address the underlying
cause.
, 6. A nurse is providing teaching to a client who is at 12 weeks' gestation and
experiencing nausea and vomiting. Which statement by the client indicates a need
for further teaching?
A. "I should eat small, frequent meals throughout the day."
B. "I will take my prenatal vitamin on an empty stomach in the morning."
C. "I can try eating dry crackers before getting out of bed."
D. "I should avoid spicy and greasy foods."
Rationale: Prenatal vitamins, especially those containing iron, can exacerbate
nausea. They should be taken with food or at bedtime to minimize gastrointestinal
upset. Small, frequent meals, dry crackers before rising, and avoiding spicy/greasy
foods are all appropriate strategies to manage nausea during pregnancy.
7. A nurse is assessing a newborn who is 24 hours old and notes a yellowish
discoloration of the skin and sclera. The newborn's bilirubin level is 8 mg/dL.
Which action should the nurse take?
A. Place the newborn under phototherapy lights immediately
B. Instruct the mother to stop breastfeeding for 24 hours
C. Continue to monitor the newborn because this is within expected parameters
for age
D. Prepare for an exchange transfusion
Rationale: Physiologic jaundice typically appears after 24 hours of age. A bilirubin
level of 8 mg/dL at 24 hours is within the expected range and does not require
immediate intervention. Phototherapy is indicated when bilirubin levels exceed
age-specific thresholds. Breastfeeding should continue to promote hydration and
bilirubin excretion. Exchange transfusion is reserved for severe hyperbilirubinemia
that is unresponsive to phototherapy.
8. A client at 39 weeks' gestation is admitted to the labor and delivery unit with
contractions every 3 to 4 minutes, lasting 60 seconds. The cervix is 5 cm dilated,
Exam 2 Questions And Correct Answers
(Verified Answers) Plus Rationales 2026
Q&A | Instant Download Pdf
1. A nurse is caring for a primigravida client at 34 weeks' gestation who reports
sudden onset of painless, bright red vaginal bleeding. The client's vital signs are
blood pressure 110/68 mm Hg, heart rate 92 bpm, respiratory rate 18/min, and
temperature 37.1°C. The fetal heart rate is 145 bpm with moderate variability.
Which action should the nurse take first?
A. Perform a sterile vaginal examination to assess cervical dilation
B. Place the client in a side-lying position and initiate continuous electronic fetal
monitoring
C. Administer betamethasone 12 mg intramuscularly
D. Prepare the client for an immediate cesarean delivery
Rationale: Painless, bright red vaginal bleeding in the third trimester is a classic
sign of placenta previa. Vaginal examination is contraindicated because it can
disrupt the placenta and cause massive hemorrhage. The nurse should first place
the client in a side-lying position to optimize uterine blood flow and initiate
continuous fetal monitoring to assess fetal well-being. Betamethasone may be
indicated if preterm delivery is anticipated, but it is not the first action. Cesarean
delivery is not the first action without further assessment.
2. A nurse is assessing a newborn who is 12 hours old. The newborn's respiratory
rate is 68 breaths/min with intermittent periods of apnea lasting 10 seconds. The
,nurse notes nasal flaring and grunting. Which intervention should the nurse
implement?
A. Continue to monitor the newborn closely because these findings are normal
B. Notify the healthcare provider immediately because these findings indicate
respiratory distress
C. Place the newborn in a prone position to improve oxygenation
D. Administer oxygen via nasal cannula at 2 L/min
Rationale: Normal newborn respiratory rate ranges from 30 to 60 breaths/min.
Periods of apnea lasting less than 15 seconds without color change are normal.
However, nasal flaring and grunting are signs of respiratory distress and require
immediate notification of the healthcare provider. Placing the newborn prone is
unsafe and increases the risk of SIDS. Supplemental oxygen should only be
administered with a provider's order and under careful monitoring.
3. A postpartum client who delivered 48 hours ago reports breast engorgement,
bilateral breast warmth, and tenderness. The client is breastfeeding her newborn.
Which instruction should the nurse provide?
A. Apply ice packs to the breasts for 20 minutes before each feeding
B. Restrict fluid intake to reduce breast milk production
C. Apply warm compresses and gently massage the breasts before feeding
D. Wear a tight-fitting bra continuously to suppress milk production
Rationale: Breast engorgement is caused by vascular congestion and milk
accumulation. Warm compresses and gentle massage before feeding help
stimulate the let-down reflex and facilitate milk flow, relieving engorgement. Ice
packs are applied after feeding to reduce swelling and discomfort, not before.
Fluid restriction is inappropriate and can lead to dehydration. Tight bras can
worsen engorgement and increase the risk of mastitis by obstructing milk flow.
,4. A nurse is reviewing the laboratory results of a client at 28 weeks' gestation.
The client's 1-hour glucose tolerance test result is 155 mg/dL. Which action should
the nurse anticipate?
A. Instruct the client to begin a 1,200-calorie diabetic diet
B. Schedule the client for a 3-hour oral glucose tolerance test
C. Diagnose the client with gestational diabetes mellitus
D. Repeat the 1-hour glucose tolerance test in 4 weeks
Rationale: A 1-hour glucose tolerance test result of 155 mg/dL is elevated (normal
is less than 140 mg/dL). This indicates a need for further testing. The 3-hour oral
glucose tolerance test is the diagnostic test for gestational diabetes. A diagnosis of
gestational diabetes is not made based solely on the 1-hour screening test.
Repeating the test in 4 weeks would delay diagnosis and management.
5. A nurse is performing an assessment on a client who is 6 hours postpartum
following a vaginal delivery. The nurse notes a firm fundus at the umbilicus,
moderate lochia rubra, and a perineal pad that is saturated with blood in 15
minutes. Which action should the nurse take first?
A. Document the findings as normal
B. Increase the rate of intravenous fluids
C. Massage the fundus and assess for bladder distension
D. Administer methylergonovine 0.2 mg intramuscularly
Rationale: A saturated perineal pad in 15 minutes indicates excessive bleeding.
The nurse should first massage the fundus to ensure it is firm and assess for
bladder distension, which can cause uterine atony and bleeding. If the fundus is
firm and bleeding continues, further interventions such as administering
uterotonics may be indicated. Documentation is important but not the first action.
Increasing IV fluids is a supportive measure but does not address the underlying
cause.
, 6. A nurse is providing teaching to a client who is at 12 weeks' gestation and
experiencing nausea and vomiting. Which statement by the client indicates a need
for further teaching?
A. "I should eat small, frequent meals throughout the day."
B. "I will take my prenatal vitamin on an empty stomach in the morning."
C. "I can try eating dry crackers before getting out of bed."
D. "I should avoid spicy and greasy foods."
Rationale: Prenatal vitamins, especially those containing iron, can exacerbate
nausea. They should be taken with food or at bedtime to minimize gastrointestinal
upset. Small, frequent meals, dry crackers before rising, and avoiding spicy/greasy
foods are all appropriate strategies to manage nausea during pregnancy.
7. A nurse is assessing a newborn who is 24 hours old and notes a yellowish
discoloration of the skin and sclera. The newborn's bilirubin level is 8 mg/dL.
Which action should the nurse take?
A. Place the newborn under phototherapy lights immediately
B. Instruct the mother to stop breastfeeding for 24 hours
C. Continue to monitor the newborn because this is within expected parameters
for age
D. Prepare for an exchange transfusion
Rationale: Physiologic jaundice typically appears after 24 hours of age. A bilirubin
level of 8 mg/dL at 24 hours is within the expected range and does not require
immediate intervention. Phototherapy is indicated when bilirubin levels exceed
age-specific thresholds. Breastfeeding should continue to promote hydration and
bilirubin excretion. Exchange transfusion is reserved for severe hyperbilirubinemia
that is unresponsive to phototherapy.
8. A client at 39 weeks' gestation is admitted to the labor and delivery unit with
contractions every 3 to 4 minutes, lasting 60 seconds. The cervix is 5 cm dilated,
