NCLEX-PN Maternal-Child Nursing Study Guide 2025
– WGU D120 OBJECTIVE ASSESSMENT ACTUAL
EXAM STUDY GUIDE 2025/2026 COMPLETE
QUESTIONS AND CORRECT DETAILED ANSWERS
WITH RATIONALES || 100% GUARANTEED PASS
<LATEST VERSION>
Pregnancy, Labor, and Delivery (Questions 1-25)
1. A nurse is teaching a prenatal class about nutrition. Which nutrient's deficiency is most
strongly associated with neural tube defects in the developing fetus?
A. Iron
B. Folic Acid ✓
C. Calcium
D. Vitamin D
Rationale: Folic acid is crucial in the first trimester for the proper closure of the neural tube,
which forms the baby's brain and spinal cord. A deficiency significantly increases the risk of
defects like spina bifida and anencephaly.
2. During a non-stress test (NST), the nurse observes two accelerations of the fetal heart rate
(FHR) of 15 beats per minute (bpm) above baseline, each lasting 15 seconds, over a 20-minute
period. How should the nurse document this finding?
A. Non-reactive
B. Reactive ✓
C. Positive
D. Negative
Rationale: A "reactive" NST is a reassuring sign of fetal well-being. The criteria are typically at
least two FHR accelerations of 15 bpm above baseline, lasting 15 seconds each, within a 20-
minute window.
3. A client at 32 weeks gestation reports swelling in her feet and ankles at the end of the day.
Which action should the nurse take first?
A. Test the urine for protein. ✓
B. Instruct her to elevate her legs.
C. Place her on a strict sodium-free diet.
,D. Check her blood pressure.
Rationale: Dependent edema is common in pregnancy due to venous congestion. However, the
nurse's priority is to assess for preeclampsia, a serious hypertensive disorder. Checking for
proteinuria (protein in the urine) along with hypertension are key diagnostic indicators.
4. A client in active labor has spontaneous rupture of membranes. The nurse's immediate
action should be to:
A. Change the client's perineal pad.
B. Assess the fetal heart rate. ✓
C. Prepare for immediate delivery.
D. Check the fluid's color and odor.
Rationale: The priority after rupture of membranes (ROM) is to assess for umbilical cord
prolapse, which is a medical emergency. A sudden drop in FHR after ROM is a classic sign. The
nurse should immediately check the FHR to ensure fetal well-being.
5. The nurse is caring for a client receiving magnesium sulfate for severe preeclampsia. Which
finding requires immediate intervention?
A. Deep tendon reflexes of +2.
B. Respiratory rate of 10 breaths per minute. ✓
C. Urine output of 40 mL/hr.
D. Complaints of feeling warm.
Rationale: Magnesium sulfate can cause respiratory depression. A respiratory rate of 10
breaths/minute is a sign of magnesium toxicity and requires immediate intervention, including
stopping the infusion and administering the antidote, calcium gluconate.
6. A postpartum client is diagnosed with a deep vein thrombosis (DVT). Which order should
the nurse anticipate?
A. Apply a heating pad to the affected leg.
B. Encourage ambulation immediately.
C. Administer anticoagulant therapy. ✓
D. Massage the affected leg vigorously.
Rationale: Anticoagulant therapy (e.g., heparin, enoxaparin) is the standard treatment for DVT
to prevent the clot from enlarging or embolizing to the lungs. The affected leg should NOT be
massaged.
7. During the fourth stage of labor, the nurse finds the client's fundus is boggy and displaced
to the right. What is the nurse's first action?
A. Administer Methergine as ordered.
B. Massage the fundus until firm.
C. Assist the client to empty her bladder. ✓
,D. Notify the provider immediately.
Rationale: A full bladder can displace the uterus and prevent it from contracting effectively,
leading to a boggy fundus and increased risk of postpartum hemorrhage. The first nursing
action is to have the client void.
8. A newborn's 1-minute Apgar score is 8. What is the best interpretation of this score by the
nurse?
A. The newborn is severely depressed and needs resuscitation.
B. The newborn is in excellent condition.
C. The newborn is mildly depressed but likely requires only routine care. ✓
D. The score is inaccurate and must be repeated.
Rationale: An Apgar score of 7-10 indicates a newborn in good condition. A score of 4-6
indicates moderate depression, and 0-3 indicates severe depression. An 8 at 1 minute is a good
score, and the baby may just need simple stimulation or suctioning.
9. Which sign is a late indicator of placental separation during the third stage of labor?
A. A sudden gush of dark blood from the vagina. ✓
B. Lengthening of the umbilical cord at the vulva.
C. Uterus becoming globular in shape.
D. Mother reports a cramping sensation.
Rationale: The gush of dark blood is a late sign. The earlier signs are the uterus becoming
globular and firm, a sudden trickle or gush of blood, and apparent lengthening of the umbilical
cord.
10. A client at 10 weeks gestation calls the clinic reporting nausea and vomiting. What is the
most appropriate advice the nurse can give?
A. "Drink large amounts of fluid with your meals."
B. "Eat small, frequent meals of dry carbohydrates." ✓
C. "Stop taking your prenatal vitamins until this resolves."
D. "Lie down immediately after eating."
Rationale: Small, frequent meals of dry, bland foods (like crackers, toast) and carbohydrates can
help manage nausea by preventing an empty stomach. Lying down after eating can worsen
reflux, and vitamins should not be stopped.
11. Which finding in a newborn 12 hours after delivery requires further assessment?
A. Acrocyanosis (blue hands and feet).
B. Heart rate of 120 bpm while sleeping.
C. Respiratory rate of 70 breaths per minute. ✓
D. Axillary temperature of 97.9°F (36.6°C).
Rationale: A normal newborn respiratory rate is 30-60 breaths/minute. A rate of 70 is
, tachypnea and could indicate respiratory distress, transient tachypnea of the newborn (TTN), or
other complications and must be investigated.
12. The nurse is preparing a client for a cesarean section. Which preoperative action is most
critical?
A. Applying sequential compression devices.
B. Verifying the signed informed consent. ✓
C. Inserting a Foley catheter.
D. Administering the preoperative antibiotic.
Rationale: While all are important, verifying a signed, informed consent is a legal and ethical
requirement before any surgical procedure. It ensures the client understands the risks, benefits,
and alternatives.
13. A client in labor is receiving Oxytocin (Pitocin) for induction. The nurse notes late
decelerations on the fetal monitor. The nurse's first action should be to:
A. Increase the IV rate.
B. Turn the client to her left side. ✓
C. Administer oxygen via face mask.
D. Stop the Oxytocin infusion.
Rationale: Late decelerations indicate uteroplacental insufficiency. The first action is to improve
placental perfusion by turning the mother to her left side to displace the uterus off the great
vessels. Stopping the Oxytocin and administering oxygen would be the next simultaneous
actions.
14. A newborn is diagnosed with physiologic jaundice. The nurse understands this is caused
by:
A. Blood group incompatibility (ABO or Rh).
B. Normal breakdown of fetal red blood cells. ✓
C. Biliary atresia.
D. Hepatic infection.
Rationale: Physiologic jaundice is a normal, common condition in newborns due to the
immature liver's inability to conjugate and excrete bilirubin quickly enough from the breakdown
of excess red blood cells. It typically appears after 24 hours.
15. The nurse is assessing for Ortolani sign in a newborn. What is the nurse testing for?
A. Developmental dysplasia of the hip (DDH). ✓
B. Brachial plexus injury.
C. Congenital heart defect.
D. Cleft palate.
Rationale: The Ortolani and Barlow maneuvers are specific tests to screen for developmental
– WGU D120 OBJECTIVE ASSESSMENT ACTUAL
EXAM STUDY GUIDE 2025/2026 COMPLETE
QUESTIONS AND CORRECT DETAILED ANSWERS
WITH RATIONALES || 100% GUARANTEED PASS
<LATEST VERSION>
Pregnancy, Labor, and Delivery (Questions 1-25)
1. A nurse is teaching a prenatal class about nutrition. Which nutrient's deficiency is most
strongly associated with neural tube defects in the developing fetus?
A. Iron
B. Folic Acid ✓
C. Calcium
D. Vitamin D
Rationale: Folic acid is crucial in the first trimester for the proper closure of the neural tube,
which forms the baby's brain and spinal cord. A deficiency significantly increases the risk of
defects like spina bifida and anencephaly.
2. During a non-stress test (NST), the nurse observes two accelerations of the fetal heart rate
(FHR) of 15 beats per minute (bpm) above baseline, each lasting 15 seconds, over a 20-minute
period. How should the nurse document this finding?
A. Non-reactive
B. Reactive ✓
C. Positive
D. Negative
Rationale: A "reactive" NST is a reassuring sign of fetal well-being. The criteria are typically at
least two FHR accelerations of 15 bpm above baseline, lasting 15 seconds each, within a 20-
minute window.
3. A client at 32 weeks gestation reports swelling in her feet and ankles at the end of the day.
Which action should the nurse take first?
A. Test the urine for protein. ✓
B. Instruct her to elevate her legs.
C. Place her on a strict sodium-free diet.
,D. Check her blood pressure.
Rationale: Dependent edema is common in pregnancy due to venous congestion. However, the
nurse's priority is to assess for preeclampsia, a serious hypertensive disorder. Checking for
proteinuria (protein in the urine) along with hypertension are key diagnostic indicators.
4. A client in active labor has spontaneous rupture of membranes. The nurse's immediate
action should be to:
A. Change the client's perineal pad.
B. Assess the fetal heart rate. ✓
C. Prepare for immediate delivery.
D. Check the fluid's color and odor.
Rationale: The priority after rupture of membranes (ROM) is to assess for umbilical cord
prolapse, which is a medical emergency. A sudden drop in FHR after ROM is a classic sign. The
nurse should immediately check the FHR to ensure fetal well-being.
5. The nurse is caring for a client receiving magnesium sulfate for severe preeclampsia. Which
finding requires immediate intervention?
A. Deep tendon reflexes of +2.
B. Respiratory rate of 10 breaths per minute. ✓
C. Urine output of 40 mL/hr.
D. Complaints of feeling warm.
Rationale: Magnesium sulfate can cause respiratory depression. A respiratory rate of 10
breaths/minute is a sign of magnesium toxicity and requires immediate intervention, including
stopping the infusion and administering the antidote, calcium gluconate.
6. A postpartum client is diagnosed with a deep vein thrombosis (DVT). Which order should
the nurse anticipate?
A. Apply a heating pad to the affected leg.
B. Encourage ambulation immediately.
C. Administer anticoagulant therapy. ✓
D. Massage the affected leg vigorously.
Rationale: Anticoagulant therapy (e.g., heparin, enoxaparin) is the standard treatment for DVT
to prevent the clot from enlarging or embolizing to the lungs. The affected leg should NOT be
massaged.
7. During the fourth stage of labor, the nurse finds the client's fundus is boggy and displaced
to the right. What is the nurse's first action?
A. Administer Methergine as ordered.
B. Massage the fundus until firm.
C. Assist the client to empty her bladder. ✓
,D. Notify the provider immediately.
Rationale: A full bladder can displace the uterus and prevent it from contracting effectively,
leading to a boggy fundus and increased risk of postpartum hemorrhage. The first nursing
action is to have the client void.
8. A newborn's 1-minute Apgar score is 8. What is the best interpretation of this score by the
nurse?
A. The newborn is severely depressed and needs resuscitation.
B. The newborn is in excellent condition.
C. The newborn is mildly depressed but likely requires only routine care. ✓
D. The score is inaccurate and must be repeated.
Rationale: An Apgar score of 7-10 indicates a newborn in good condition. A score of 4-6
indicates moderate depression, and 0-3 indicates severe depression. An 8 at 1 minute is a good
score, and the baby may just need simple stimulation or suctioning.
9. Which sign is a late indicator of placental separation during the third stage of labor?
A. A sudden gush of dark blood from the vagina. ✓
B. Lengthening of the umbilical cord at the vulva.
C. Uterus becoming globular in shape.
D. Mother reports a cramping sensation.
Rationale: The gush of dark blood is a late sign. The earlier signs are the uterus becoming
globular and firm, a sudden trickle or gush of blood, and apparent lengthening of the umbilical
cord.
10. A client at 10 weeks gestation calls the clinic reporting nausea and vomiting. What is the
most appropriate advice the nurse can give?
A. "Drink large amounts of fluid with your meals."
B. "Eat small, frequent meals of dry carbohydrates." ✓
C. "Stop taking your prenatal vitamins until this resolves."
D. "Lie down immediately after eating."
Rationale: Small, frequent meals of dry, bland foods (like crackers, toast) and carbohydrates can
help manage nausea by preventing an empty stomach. Lying down after eating can worsen
reflux, and vitamins should not be stopped.
11. Which finding in a newborn 12 hours after delivery requires further assessment?
A. Acrocyanosis (blue hands and feet).
B. Heart rate of 120 bpm while sleeping.
C. Respiratory rate of 70 breaths per minute. ✓
D. Axillary temperature of 97.9°F (36.6°C).
Rationale: A normal newborn respiratory rate is 30-60 breaths/minute. A rate of 70 is
, tachypnea and could indicate respiratory distress, transient tachypnea of the newborn (TTN), or
other complications and must be investigated.
12. The nurse is preparing a client for a cesarean section. Which preoperative action is most
critical?
A. Applying sequential compression devices.
B. Verifying the signed informed consent. ✓
C. Inserting a Foley catheter.
D. Administering the preoperative antibiotic.
Rationale: While all are important, verifying a signed, informed consent is a legal and ethical
requirement before any surgical procedure. It ensures the client understands the risks, benefits,
and alternatives.
13. A client in labor is receiving Oxytocin (Pitocin) for induction. The nurse notes late
decelerations on the fetal monitor. The nurse's first action should be to:
A. Increase the IV rate.
B. Turn the client to her left side. ✓
C. Administer oxygen via face mask.
D. Stop the Oxytocin infusion.
Rationale: Late decelerations indicate uteroplacental insufficiency. The first action is to improve
placental perfusion by turning the mother to her left side to displace the uterus off the great
vessels. Stopping the Oxytocin and administering oxygen would be the next simultaneous
actions.
14. A newborn is diagnosed with physiologic jaundice. The nurse understands this is caused
by:
A. Blood group incompatibility (ABO or Rh).
B. Normal breakdown of fetal red blood cells. ✓
C. Biliary atresia.
D. Hepatic infection.
Rationale: Physiologic jaundice is a normal, common condition in newborns due to the
immature liver's inability to conjugate and excrete bilirubin quickly enough from the breakdown
of excess red blood cells. It typically appears after 24 hours.
15. The nurse is assessing for Ortolani sign in a newborn. What is the nurse testing for?
A. Developmental dysplasia of the hip (DDH). ✓
B. Brachial plexus injury.
C. Congenital heart defect.
D. Cleft palate.
Rationale: The Ortolani and Barlow maneuvers are specific tests to screen for developmental
