Saunders Comprehensive Review for the NCLEX-
PN® Examination
9th Edition
• Author(s)Linda Anne Silvestri; Angela Silvestri
MATERNITY AND NEWBORN NURSING (HIGH-
DEMAND AREA) TEST BANK
1 — Antepartum assessment (single best answer)
A 28-year-old primigravida at 36 weeks’ gestation tells the nurse
she has noticed a sudden gush of fluid while getting out of bed.
She is afebrile and reports no abdominal pain. On exam the
fundal height is appropriate and there is a pooling of clear fluid
in the posterior fornix. Which action should the nurse perform
first?
A. Obtain a nitrazine (pH) test of the fluid.
B. Assess the fetal heart rate (FHR) with an external monitor.
C. Ask the patient to ambulate to see if the fluid continues.
D. Obtain a urine specimen for culture.
Correct answer: B
Rationale (correct): The first action when rupture of
membranes (ROM) is suspected is to assess fetal well-being via
,fetal heart rate monitoring. Maternal ROM increases the risk of
cord prolapse, infection, and fetal compromise; immediate
assessment of the FHR will detect bradycardia or decelerations
indicating acute compromise. This is aligned with the priority of
airway/breathing/circulation equivalents in obstetrics — assess
viability and safety first.
Rationales (incorrect):
A — Nitrazine/pH testing helps confirm ROM (alkaline pH) but is
not the immediate priority; if the fetus is compromised,
monitoring must be done first. Additionally, false positives can
occur with blood or semen.
C — Ambulation risks cord prolapse if membranes have
ruptured and may worsen fetal compromise; do not ambulate
before assessing FHR.
D — Urine culture is irrelevant as an immediate action;
infection risk is considered later after confirming ROM and fetal
status.
2 — High-risk pregnancy: preeclampsia (single best answer)
A patient at 34 weeks’ gestation is admitted with severe
preeclampsia. Her BP is 170/110 mm Hg, urine protein 3+, and
deep tendon reflexes are hyperactive with clonus. The physician
orders magnesium sulfate IV. Which outcome indicates the
magnesium is having the desired therapeutic effect?
,A. Decreased edema in the lower extremities.
B. Reduction in seizure activity (prevention of eclampsia).
C. Improved protein excretion in the urine.
D. Immediate reduction of blood pressure to <140/90 mm Hg.
Correct answer: B
Rationale (correct): Magnesium sulfate is used primarily as an
anticonvulsant to prevent eclamptic seizures in severe
preeclampsia by depressing central nervous system irritability.
Its therapeutic effect is seizure prophylaxis and reduction of
neuromuscular hyperexcitability.
Rationales (incorrect):
A — Magnesium does not directly reduce edema; edema in
preeclampsia is related to capillary permeability and fluid shifts.
C — Magnesium does not correct proteinuria; proteinuria
reflects glomerular endothelial dysfunction and may improve
only after delivery.
D — Magnesium has little direct antihypertensive effect;
antihypertensive medications (e.g., labetalol, hydralazine) are
used to lower BP.
3 — Prenatal education (single best answer)
During a prenatal class a woman in her third trimester asks how
often she should feel fetal movements. The nurse’s best
response is:
, A. “You should feel 10 movements within 1 hour every day.”
B. “You should feel at least 10 movements within 2 hours; if not,
call your provider.”
C. “If you don’t feel the baby move for 12 hours, you need to go
to the hospital.”
D. “Fetal movement counts are not useful in the third
trimester.”
Correct answer: B
Rationale (correct): A commonly taught, evidence-based
guideline: if a woman does not perceive at least 10 fetal
movements within 2 hours during a period of normal activity,
she should contact her provider for further evaluation (often a
nonstress test). This balances sensitivity and practicality and
aligns with prenatal education standards.
Rationales (incorrect):
A — 10 movements in 1 hour is overly strict for routine daily
monitoring; it’s used in some protocols for initial testing but not
a universal everyday rule.
C — Waiting 12 hours is too long and risks delayed recognition
of fetal compromise.
D — Fetal movement counting is a validated screening tool in
the third trimester.
4 — Labor & delivery: FHR strip interpretation (single best
answer)
PN® Examination
9th Edition
• Author(s)Linda Anne Silvestri; Angela Silvestri
MATERNITY AND NEWBORN NURSING (HIGH-
DEMAND AREA) TEST BANK
1 — Antepartum assessment (single best answer)
A 28-year-old primigravida at 36 weeks’ gestation tells the nurse
she has noticed a sudden gush of fluid while getting out of bed.
She is afebrile and reports no abdominal pain. On exam the
fundal height is appropriate and there is a pooling of clear fluid
in the posterior fornix. Which action should the nurse perform
first?
A. Obtain a nitrazine (pH) test of the fluid.
B. Assess the fetal heart rate (FHR) with an external monitor.
C. Ask the patient to ambulate to see if the fluid continues.
D. Obtain a urine specimen for culture.
Correct answer: B
Rationale (correct): The first action when rupture of
membranes (ROM) is suspected is to assess fetal well-being via
,fetal heart rate monitoring. Maternal ROM increases the risk of
cord prolapse, infection, and fetal compromise; immediate
assessment of the FHR will detect bradycardia or decelerations
indicating acute compromise. This is aligned with the priority of
airway/breathing/circulation equivalents in obstetrics — assess
viability and safety first.
Rationales (incorrect):
A — Nitrazine/pH testing helps confirm ROM (alkaline pH) but is
not the immediate priority; if the fetus is compromised,
monitoring must be done first. Additionally, false positives can
occur with blood or semen.
C — Ambulation risks cord prolapse if membranes have
ruptured and may worsen fetal compromise; do not ambulate
before assessing FHR.
D — Urine culture is irrelevant as an immediate action;
infection risk is considered later after confirming ROM and fetal
status.
2 — High-risk pregnancy: preeclampsia (single best answer)
A patient at 34 weeks’ gestation is admitted with severe
preeclampsia. Her BP is 170/110 mm Hg, urine protein 3+, and
deep tendon reflexes are hyperactive with clonus. The physician
orders magnesium sulfate IV. Which outcome indicates the
magnesium is having the desired therapeutic effect?
,A. Decreased edema in the lower extremities.
B. Reduction in seizure activity (prevention of eclampsia).
C. Improved protein excretion in the urine.
D. Immediate reduction of blood pressure to <140/90 mm Hg.
Correct answer: B
Rationale (correct): Magnesium sulfate is used primarily as an
anticonvulsant to prevent eclamptic seizures in severe
preeclampsia by depressing central nervous system irritability.
Its therapeutic effect is seizure prophylaxis and reduction of
neuromuscular hyperexcitability.
Rationales (incorrect):
A — Magnesium does not directly reduce edema; edema in
preeclampsia is related to capillary permeability and fluid shifts.
C — Magnesium does not correct proteinuria; proteinuria
reflects glomerular endothelial dysfunction and may improve
only after delivery.
D — Magnesium has little direct antihypertensive effect;
antihypertensive medications (e.g., labetalol, hydralazine) are
used to lower BP.
3 — Prenatal education (single best answer)
During a prenatal class a woman in her third trimester asks how
often she should feel fetal movements. The nurse’s best
response is:
, A. “You should feel 10 movements within 1 hour every day.”
B. “You should feel at least 10 movements within 2 hours; if not,
call your provider.”
C. “If you don’t feel the baby move for 12 hours, you need to go
to the hospital.”
D. “Fetal movement counts are not useful in the third
trimester.”
Correct answer: B
Rationale (correct): A commonly taught, evidence-based
guideline: if a woman does not perceive at least 10 fetal
movements within 2 hours during a period of normal activity,
she should contact her provider for further evaluation (often a
nonstress test). This balances sensitivity and practicality and
aligns with prenatal education standards.
Rationales (incorrect):
A — 10 movements in 1 hour is overly strict for routine daily
monitoring; it’s used in some protocols for initial testing but not
a universal everyday rule.
C — Waiting 12 hours is too long and risks delayed recognition
of fetal compromise.
D — Fetal movement counting is a validated screening tool in
the third trimester.
4 — Labor & delivery: FHR strip interpretation (single best
answer)
