NCLEX RN Maternal Newborn Nursing
Exam 2 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026
1. A nurse is caring for a client at 34 weeks’ gestation who has painless bright-
red vaginal bleeding. Which condition should the nurse suspect?
A. Abruptio placentae
B. Placenta previa
C. Preterm labor
D. Uterine rupture
Answer: B. Placenta previa
Rationale: Placenta previa classically presents with painless, bright-red
vaginal bleeding in the second or third trimester. Vaginal examination should
be avoided until placenta location is confirmed because manipulation can
cause severe hemorrhage.
2. A client with severe preeclampsia is receiving magnesium sulfate. Which
finding requires immediate intervention?
A. Respiratory rate of 10/min
B. Urine output of 40 mL/hr
C. Blood pressure of 150/94 mm Hg
D. Patellar reflexes of 2+
Answer: A. Respiratory rate of 10/min
Rationale: Magnesium sulfate toxicity can cause respiratory depression. A
respiratory rate below 12/min is concerning and requires stopping the
infusion and notifying the provider. Calcium gluconate is the antidote.
,3. Which assessment finding is most concerning in a client receiving
magnesium sulfate?
A. Warm flushed skin
B. Mild nausea
C. Absent deep tendon reflexes
D. Urine output of 50 mL/hr
Answer: C. Absent deep tendon reflexes
Rationale: Loss of deep tendon reflexes is an early sign of magnesium toxicity.
The nurse should stop the infusion and notify the provider.
4. A postpartum client has a boggy uterus and heavy lochia. What should the
nurse do first?
A. Notify the health care provider
B. Administer oxytocin
C. Massage the uterine fundus
D. Prepare the client for surgery
Answer: C. Massage the uterine fundus
Rationale: Uterine atony is a common cause of postpartum hemorrhage. The
immediate nursing intervention is firm fundal massage to stimulate uterine
contraction and reduce bleeding.
5. A postpartum client has a firm uterus but continues to have heavy vaginal
bleeding. Which condition should the nurse suspect?
A. Uterine atony
B. Vaginal or cervical laceration
C. Bladder distention
D. Retained urine
Answer: B. Vaginal or cervical laceration
,Rationale: Persistent heavy bleeding despite a firm, contracted uterus
suggests genital tract trauma such as a cervical or vaginal laceration.
6. Which lochia finding is expected during the first few days after birth?
A. Lochia alba
B. Lochia serosa
C. Lochia rubra
D. Purulent lochia
Answer: C. Lochia rubra
Rationale: Lochia rubra is the normal dark-red vaginal discharge occurring
during approximately the first 3–4 days postpartum.
7. A client who is breastfeeding asks when milk production will increase
substantially. Which response is best?
A. “Milk production usually increases around the third to fifth postpartum day.”
B. “Mature milk is normally present immediately after birth.”
C. “Milk production begins approximately 2 weeks after birth.”
D. “Breast milk production depends entirely on formula supplementation.”
Answer: A. “Milk production usually increases around the third to fifth
postpartum day.”
Rationale: Colostrum is produced initially. Transitional and mature milk
production generally increases around days 3–5 postpartum.
8. Which hormone is primarily responsible for milk production?
A. Oxytocin
B. Prolactin
C. Estrogen
D. Progesterone
Answer: B. Prolactin
, Rationale: Prolactin stimulates milk production. Oxytocin is responsible
primarily for milk ejection or let-down.
9. Which hormone causes the milk ejection reflex during breastfeeding?
A. Prolactin
B. Oxytocin
C. Estrogen
D. Human chorionic gonadotropin
Answer: B. Oxytocin
Rationale: Oxytocin causes contraction of myoepithelial cells around the
mammary alveoli, resulting in milk ejection.
10. A newborn is being assessed immediately after birth. Which finding
requires priority intervention?
A. Acrocyanosis
B. Respiratory rate of 44/min
C. Heart rate of 140/min
D. Central cyanosis
Answer: D. Central cyanosis
Rationale: Central cyanosis indicates inadequate oxygenation and requires
immediate assessment and intervention. Acrocyanosis of the hands and feet
can be normal during the transition after birth.
11. Which medication is routinely administered to newborns to prevent
vitamin K deficiency bleeding?
A. Vitamin C
B. Vitamin K
C. Iron dextran
D. Folic acid
Exam 2 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026
1. A nurse is caring for a client at 34 weeks’ gestation who has painless bright-
red vaginal bleeding. Which condition should the nurse suspect?
A. Abruptio placentae
B. Placenta previa
C. Preterm labor
D. Uterine rupture
Answer: B. Placenta previa
Rationale: Placenta previa classically presents with painless, bright-red
vaginal bleeding in the second or third trimester. Vaginal examination should
be avoided until placenta location is confirmed because manipulation can
cause severe hemorrhage.
2. A client with severe preeclampsia is receiving magnesium sulfate. Which
finding requires immediate intervention?
A. Respiratory rate of 10/min
B. Urine output of 40 mL/hr
C. Blood pressure of 150/94 mm Hg
D. Patellar reflexes of 2+
Answer: A. Respiratory rate of 10/min
Rationale: Magnesium sulfate toxicity can cause respiratory depression. A
respiratory rate below 12/min is concerning and requires stopping the
infusion and notifying the provider. Calcium gluconate is the antidote.
,3. Which assessment finding is most concerning in a client receiving
magnesium sulfate?
A. Warm flushed skin
B. Mild nausea
C. Absent deep tendon reflexes
D. Urine output of 50 mL/hr
Answer: C. Absent deep tendon reflexes
Rationale: Loss of deep tendon reflexes is an early sign of magnesium toxicity.
The nurse should stop the infusion and notify the provider.
4. A postpartum client has a boggy uterus and heavy lochia. What should the
nurse do first?
A. Notify the health care provider
B. Administer oxytocin
C. Massage the uterine fundus
D. Prepare the client for surgery
Answer: C. Massage the uterine fundus
Rationale: Uterine atony is a common cause of postpartum hemorrhage. The
immediate nursing intervention is firm fundal massage to stimulate uterine
contraction and reduce bleeding.
5. A postpartum client has a firm uterus but continues to have heavy vaginal
bleeding. Which condition should the nurse suspect?
A. Uterine atony
B. Vaginal or cervical laceration
C. Bladder distention
D. Retained urine
Answer: B. Vaginal or cervical laceration
,Rationale: Persistent heavy bleeding despite a firm, contracted uterus
suggests genital tract trauma such as a cervical or vaginal laceration.
6. Which lochia finding is expected during the first few days after birth?
A. Lochia alba
B. Lochia serosa
C. Lochia rubra
D. Purulent lochia
Answer: C. Lochia rubra
Rationale: Lochia rubra is the normal dark-red vaginal discharge occurring
during approximately the first 3–4 days postpartum.
7. A client who is breastfeeding asks when milk production will increase
substantially. Which response is best?
A. “Milk production usually increases around the third to fifth postpartum day.”
B. “Mature milk is normally present immediately after birth.”
C. “Milk production begins approximately 2 weeks after birth.”
D. “Breast milk production depends entirely on formula supplementation.”
Answer: A. “Milk production usually increases around the third to fifth
postpartum day.”
Rationale: Colostrum is produced initially. Transitional and mature milk
production generally increases around days 3–5 postpartum.
8. Which hormone is primarily responsible for milk production?
A. Oxytocin
B. Prolactin
C. Estrogen
D. Progesterone
Answer: B. Prolactin
, Rationale: Prolactin stimulates milk production. Oxytocin is responsible
primarily for milk ejection or let-down.
9. Which hormone causes the milk ejection reflex during breastfeeding?
A. Prolactin
B. Oxytocin
C. Estrogen
D. Human chorionic gonadotropin
Answer: B. Oxytocin
Rationale: Oxytocin causes contraction of myoepithelial cells around the
mammary alveoli, resulting in milk ejection.
10. A newborn is being assessed immediately after birth. Which finding
requires priority intervention?
A. Acrocyanosis
B. Respiratory rate of 44/min
C. Heart rate of 140/min
D. Central cyanosis
Answer: D. Central cyanosis
Rationale: Central cyanosis indicates inadequate oxygenation and requires
immediate assessment and intervention. Acrocyanosis of the hands and feet
can be normal during the transition after birth.
11. Which medication is routinely administered to newborns to prevent
vitamin K deficiency bleeding?
A. Vitamin C
B. Vitamin K
C. Iron dextran
D. Folic acid
