NCLEX RN Maternal Newborn Nursing
Exam 1 Practice Exam Questions And
Correct Answers (Verified Answers) Plus
Rationales 2026 Q&A | Instant
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A pregnant woman at 28 weeks gestation presents to the clinic with complaints of
frequent heartburn and indigestion. She asks the nurse for advice on managing
these symptoms. Which of the following recommendations is most appropriate
for the nurse to provide?
Answer: B) Advise the client to eat small, frequent meals and avoid lying down
immediately after eating.
Rationale: Heartburn in pregnancy is caused by progesterone-induced relaxation
of the lower esophageal sphincter and mechanical pressure from the gravid
uterus. The most effective nonpharmacologic management includes eating
small, frequent meals to prevent gastric distension, avoiding lying down for at
least 1 to 2 hours after meals to allow gravity to keep gastric contents in the
stomach, and elevating the head of the bed. Antacids containing aluminum or
magnesium may be used cautiously, but sodium bicarbonate and calcium
carbonate are avoided due to risks of fluid retention or hypercalcemia. The other
options are incorrect because eating large meals increases pressure on the
stomach, drinking large amounts of fluids with meals distends the stomach, and
lying down immediately after eating worsens reflux.
,A primigravid client at 39 weeks gestation presents to the labor and delivery unit
with contractions every 3 to 4 minutes lasting 60 seconds. She is in active labor
with a cervical dilation of 5 cm and 80% effacement. The fetal heart rate tracing
shows a baseline of 140 beats per minute with moderate variability. Variable
decelerations are noted, dropping to 100 beats per minute for 15 seconds and
returning to baseline. What is the nurse’s priority action?
Answer: C) Reposition the client to her left side.
Rationale: Variable decelerations are most commonly caused by umbilical cord
compression during uterine contractions. The priority nursing intervention for
variable decelerations is to change the mother’s position to relieve pressure on
the cord, such as turning her to the left lateral position or repositioning to
alleviate any cord entanglement or compression. This action improves
uteroplacental blood flow and may resolve the cord compression. While
checking the cervix and assessing for prolapsed cord are important,
repositioning is the immediate first step. Administering oxygen would be
appropriate for late decelerations, and increasing the IV fluid rate is for
hypovolemia; neither is the primary action for variable decelerations.
A nurse is assessing a newborn who was born vaginally 2 hours ago. The newborn
has a heart rate of 120 beats per minute, respirations of 44 breaths per minute,
temperature of 36.8°C (98.2°F), and a blood glucose level of 45 mg/dL. The nurse
notes mild acrocyanosis and a small caput succedaneum. Which finding requires
immediate intervention?
Answer: D) The newborn’s respiratory rate of 44 breaths per minute.
***Rationale: A normal newborn respiratory rate is between 30 and 60 breaths
per minute, so 44 breaths per minute is within the normal range and does not
require intervention. Acrocyanosis (blue discoloration of the hands and feet) is
normal in the first 24 hours due to peripheral vasomotor instability. A caput
succedaneum is a benign, localized edema of the scalp that resolves
spontaneously. A blood glucose level of 45 mg/dL is borderline low but may be
,acceptable if the newborn is asymptomatic; however, the threshold for
hypoglycemia in newborns is often considered below 40 mg/dL, and some
protocols recommend intervention at <45 mg/dL, but many sources consider 45
to be acceptable. Wait, the question asks which finding requires immediate
intervention. Actually, let's re-evaluate: The correct answer should be the one that
is abnormal. Respiratory rate of 44 is normal. Blood glucose 45 is borderline but
many sources say treat if <40 or <45. However, the question likely expects a
different answer. Let me check: Acrocyanosis is normal. Caput is normal. Heart
rate 120 is normal. Temperature 36.8°C is normal (axillary). Respirations 44 is
normal. So all are normal. But the question might be tricky. Perhaps the blood
glucose of 45 mg/dL is actually the abnormal one because the normal threshold is
>45 or >40. In some protocols, newborn hypoglycemia is defined as <45 mg/dL, so
45 is exactly at the cutoff. Some sources say treat if <46. However, the question
asks "requires immediate intervention" - if the blood glucose is 45, the nurse
might recheck it or feed the baby. But let's look at the options. Actually, the
options are not listed. The prompt gives the scenario and asks "Which finding
requires immediate intervention?" but the answer is given as D) The newborn’s
respiratory rate of 44 breaths per minute. This is clearly wrong because 44 is
normal. Let me correct this. I need to make sure all answers are correct. I will
rewrite this question with correct answer.
Let me generate a new question 3. I will be meticulous.
A nurse is caring for a term newborn who is 2 hours old. The newborn has a heart
rate of 130 beats per minute, respiratory rate of 58 breaths per minute, and
temperature of 37.1°C axillary. The newborn is jittery, has a high-pitched cry, and
has a blood glucose level of 32 mg/dL. What is the nurse's priority action?
Answer: A) Administer oral glucose gel or formula feeding as ordered.
Rationale: The newborn has symptomatic hypoglycemia, defined as a blood
glucose level below 40 mg/dL (some sources use <45 mg/dL) accompanied by
clinical signs such as jitteriness, high-pitched cry, lethargy, or poor feeding. The
, priority is to increase the blood glucose level rapidly. In a stable, awake newborn
with mild symptoms, oral glucose gel or a small formula feeding is the first-line
intervention. If the newborn cannot feed safely or is severely symptomatic, IV
dextrose would be indicated. Wrapping the newborn to maintain temperature is
important but does not address hypoglycemia. Notifying the provider is
necessary but the nurse should act immediately to treat the hypoglycemia.
Measuring the temperature is not the priority in this scenario.
A pregnant client at 34 weeks gestation presents with a blood pressure of 150/95
mm Hg, 2+ proteinuria, and generalized edema. She reports a severe headache
and visual disturbances. The provider orders a continuous infusion of magnesium
sulfate. Which assessment finding indicates magnesium toxicity and requires
immediate discontinuation of the infusion?
Answer: C) Respiratory rate of 10 breaths per minute and absent deep tendon
reflexes.
Rationale: Magnesium sulfate is administered to prevent seizures in
preeclampsia. The therapeutic range is 4 to 8 mEq/L. Signs of magnesium
toxicity include respiratory depression (respiratory rate <12 breaths per minute),
loss of deep tendon reflexes (hyporeflexia), oliguria, and eventually cardiac
arrest. The priority action when toxicity is suspected is to discontinue the
infusion immediately and administer calcium gluconate as the antidote. A
decreased urine output of <30 mL/hour is a sign of toxicity but not as acute as
respiratory depression. Serum magnesium levels of 6 mEq/L are within the
therapeutic range. A headache and blurred vision are symptoms of worsening
preeclampsia, not magnesium toxicity.
A nurse is providing discharge teaching to a postpartum client who is
breastfeeding her newborn. The client asks about the recommended vitamin
supplementation for the baby. Which response by the nurse is most accurate?
Exam 1 Practice Exam Questions And
Correct Answers (Verified Answers) Plus
Rationales 2026 Q&A | Instant
Download Pdf
A pregnant woman at 28 weeks gestation presents to the clinic with complaints of
frequent heartburn and indigestion. She asks the nurse for advice on managing
these symptoms. Which of the following recommendations is most appropriate
for the nurse to provide?
Answer: B) Advise the client to eat small, frequent meals and avoid lying down
immediately after eating.
Rationale: Heartburn in pregnancy is caused by progesterone-induced relaxation
of the lower esophageal sphincter and mechanical pressure from the gravid
uterus. The most effective nonpharmacologic management includes eating
small, frequent meals to prevent gastric distension, avoiding lying down for at
least 1 to 2 hours after meals to allow gravity to keep gastric contents in the
stomach, and elevating the head of the bed. Antacids containing aluminum or
magnesium may be used cautiously, but sodium bicarbonate and calcium
carbonate are avoided due to risks of fluid retention or hypercalcemia. The other
options are incorrect because eating large meals increases pressure on the
stomach, drinking large amounts of fluids with meals distends the stomach, and
lying down immediately after eating worsens reflux.
,A primigravid client at 39 weeks gestation presents to the labor and delivery unit
with contractions every 3 to 4 minutes lasting 60 seconds. She is in active labor
with a cervical dilation of 5 cm and 80% effacement. The fetal heart rate tracing
shows a baseline of 140 beats per minute with moderate variability. Variable
decelerations are noted, dropping to 100 beats per minute for 15 seconds and
returning to baseline. What is the nurse’s priority action?
Answer: C) Reposition the client to her left side.
Rationale: Variable decelerations are most commonly caused by umbilical cord
compression during uterine contractions. The priority nursing intervention for
variable decelerations is to change the mother’s position to relieve pressure on
the cord, such as turning her to the left lateral position or repositioning to
alleviate any cord entanglement or compression. This action improves
uteroplacental blood flow and may resolve the cord compression. While
checking the cervix and assessing for prolapsed cord are important,
repositioning is the immediate first step. Administering oxygen would be
appropriate for late decelerations, and increasing the IV fluid rate is for
hypovolemia; neither is the primary action for variable decelerations.
A nurse is assessing a newborn who was born vaginally 2 hours ago. The newborn
has a heart rate of 120 beats per minute, respirations of 44 breaths per minute,
temperature of 36.8°C (98.2°F), and a blood glucose level of 45 mg/dL. The nurse
notes mild acrocyanosis and a small caput succedaneum. Which finding requires
immediate intervention?
Answer: D) The newborn’s respiratory rate of 44 breaths per minute.
***Rationale: A normal newborn respiratory rate is between 30 and 60 breaths
per minute, so 44 breaths per minute is within the normal range and does not
require intervention. Acrocyanosis (blue discoloration of the hands and feet) is
normal in the first 24 hours due to peripheral vasomotor instability. A caput
succedaneum is a benign, localized edema of the scalp that resolves
spontaneously. A blood glucose level of 45 mg/dL is borderline low but may be
,acceptable if the newborn is asymptomatic; however, the threshold for
hypoglycemia in newborns is often considered below 40 mg/dL, and some
protocols recommend intervention at <45 mg/dL, but many sources consider 45
to be acceptable. Wait, the question asks which finding requires immediate
intervention. Actually, let's re-evaluate: The correct answer should be the one that
is abnormal. Respiratory rate of 44 is normal. Blood glucose 45 is borderline but
many sources say treat if <40 or <45. However, the question likely expects a
different answer. Let me check: Acrocyanosis is normal. Caput is normal. Heart
rate 120 is normal. Temperature 36.8°C is normal (axillary). Respirations 44 is
normal. So all are normal. But the question might be tricky. Perhaps the blood
glucose of 45 mg/dL is actually the abnormal one because the normal threshold is
>45 or >40. In some protocols, newborn hypoglycemia is defined as <45 mg/dL, so
45 is exactly at the cutoff. Some sources say treat if <46. However, the question
asks "requires immediate intervention" - if the blood glucose is 45, the nurse
might recheck it or feed the baby. But let's look at the options. Actually, the
options are not listed. The prompt gives the scenario and asks "Which finding
requires immediate intervention?" but the answer is given as D) The newborn’s
respiratory rate of 44 breaths per minute. This is clearly wrong because 44 is
normal. Let me correct this. I need to make sure all answers are correct. I will
rewrite this question with correct answer.
Let me generate a new question 3. I will be meticulous.
A nurse is caring for a term newborn who is 2 hours old. The newborn has a heart
rate of 130 beats per minute, respiratory rate of 58 breaths per minute, and
temperature of 37.1°C axillary. The newborn is jittery, has a high-pitched cry, and
has a blood glucose level of 32 mg/dL. What is the nurse's priority action?
Answer: A) Administer oral glucose gel or formula feeding as ordered.
Rationale: The newborn has symptomatic hypoglycemia, defined as a blood
glucose level below 40 mg/dL (some sources use <45 mg/dL) accompanied by
clinical signs such as jitteriness, high-pitched cry, lethargy, or poor feeding. The
, priority is to increase the blood glucose level rapidly. In a stable, awake newborn
with mild symptoms, oral glucose gel or a small formula feeding is the first-line
intervention. If the newborn cannot feed safely or is severely symptomatic, IV
dextrose would be indicated. Wrapping the newborn to maintain temperature is
important but does not address hypoglycemia. Notifying the provider is
necessary but the nurse should act immediately to treat the hypoglycemia.
Measuring the temperature is not the priority in this scenario.
A pregnant client at 34 weeks gestation presents with a blood pressure of 150/95
mm Hg, 2+ proteinuria, and generalized edema. She reports a severe headache
and visual disturbances. The provider orders a continuous infusion of magnesium
sulfate. Which assessment finding indicates magnesium toxicity and requires
immediate discontinuation of the infusion?
Answer: C) Respiratory rate of 10 breaths per minute and absent deep tendon
reflexes.
Rationale: Magnesium sulfate is administered to prevent seizures in
preeclampsia. The therapeutic range is 4 to 8 mEq/L. Signs of magnesium
toxicity include respiratory depression (respiratory rate <12 breaths per minute),
loss of deep tendon reflexes (hyporeflexia), oliguria, and eventually cardiac
arrest. The priority action when toxicity is suspected is to discontinue the
infusion immediately and administer calcium gluconate as the antidote. A
decreased urine output of <30 mL/hour is a sign of toxicity but not as acute as
respiratory depression. Serum magnesium levels of 6 mEq/L are within the
therapeutic range. A headache and blurred vision are symptoms of worsening
preeclampsia, not magnesium toxicity.
A nurse is providing discharge teaching to a postpartum client who is
breastfeeding her newborn. The client asks about the recommended vitamin
supplementation for the baby. Which response by the nurse is most accurate?
