RN MATERNAL NEWBORN ONLINE PRACTICE
EXAM 2025 COMPLETE STUDY GUIDE
QUESTIONS AND SOLUTIONS GRADED A+
◉ A nurse is caring for a client who has uterine atony and is
experiencing postpartum hemorrhage. Which of the following actions is
the nurse's priority?
A. Check the client's capillary refill.
B. Massage the client's fundus.
C. Insert an indwelling urinary catheter for the client.
It is important for the nurse to insert an indwelling urinary catheter to
assess the client for hypovolemia. The most objective assessment of
oxygenation and organ perfusion is urinary output of at least 30 ml/hr.
However, another action is the nurse's priority.
D. Prepare the client for a blood transfusion.. Answer: B. Massage the
clients fundus.
- Uterine atony and postpartum hemorrhage indicate that this client is at
the greatest risk for hypovolemic shock. This can compromise the
perfusion to the client's vital organs, which can lead to death. Therefore,
,the nurse's priority is to massage the client's fundus to minimize blood
loss.
Rationale:
A. It is important for the nurse to monitor capillary refill to track
baseline data for this client. Noninvasive assessments of cardiac output
for clients who are experiencing postpartum hemorrhage include
assessing: capillary refill; skin color, temperature, and turgor; level of
consciousness; neck veins; and mucous membranes. However, another
action is the nurse's priority.
C. It is important for the nurse to insert an indwelling urinary catheter to
assess the client for hypovolemia. The most objective assessment of
oxygenation and organ perfusion is urinary output of at least 30 ml/hr.
However, another action is the nurse's priority.
D. It is important for the nurse to prepare the client for a blood
transfusion to replace the amount of blood lost from postpartum
hemorrhage. It is crucial to restore circulating blood volume. However,
another action is the nurse's priority.
◉ A nurse is caring for a client who is to receive oxytocin to augment
her labor. Which of the following findings contraindicates the initiation
of the oxytocin infusion and should be reported to the provider?
,A. Late decelerations
B. Moderate variability of the FHR
C. Cessation of uterine dilation
D. Prolonged active phase of labor. Answer: A. Late declarations
- Late decelerations are indicative of uteroplacental insufficiency.
Therefore, this is a contraindication for the administration of oxytocin
and should be reported to the provider.
Rationale:
B. Moderate variability of the FHR is an expected assessment finding
associated with normal fetal acid-base balance. It is not a
contraindication to the administration of oxytocin.
C. Cessation of uterine dilation is an indication for the initiation of an
oxytocin infusion to augment the client's labor progression.
D. A prolonged active phase of labor is an indication for the initiation of
an oxytocin infusion to augment the client's labor progression.
, ◉ A nurse is assessing a client who has severe preeclampsia. Which of
the following manifestations should the nurse expect?
A. 2+ deep tendon reflexes
B. Proteinuria of 200 mg in a 24-hr specimen
C. Polyuria
D. Blurred vision. Answer: D. Blurred vision
- The nurse should identify that a client who has severe preeclampsia can
have arteriolar vasospasms and decreased blood flow to the retina which
can lead to visual disturbances, such as blurred vision, double vision, or
dark spots in the visual field.
Rationale:
A. The nurse should identify that a client who has severe preeclampsia
can have hyperactive reflexes of 3+ or 4+. Deep tendon reflexes of 2+ is
indicative of an active or expected response.
EXAM 2025 COMPLETE STUDY GUIDE
QUESTIONS AND SOLUTIONS GRADED A+
◉ A nurse is caring for a client who has uterine atony and is
experiencing postpartum hemorrhage. Which of the following actions is
the nurse's priority?
A. Check the client's capillary refill.
B. Massage the client's fundus.
C. Insert an indwelling urinary catheter for the client.
It is important for the nurse to insert an indwelling urinary catheter to
assess the client for hypovolemia. The most objective assessment of
oxygenation and organ perfusion is urinary output of at least 30 ml/hr.
However, another action is the nurse's priority.
D. Prepare the client for a blood transfusion.. Answer: B. Massage the
clients fundus.
- Uterine atony and postpartum hemorrhage indicate that this client is at
the greatest risk for hypovolemic shock. This can compromise the
perfusion to the client's vital organs, which can lead to death. Therefore,
,the nurse's priority is to massage the client's fundus to minimize blood
loss.
Rationale:
A. It is important for the nurse to monitor capillary refill to track
baseline data for this client. Noninvasive assessments of cardiac output
for clients who are experiencing postpartum hemorrhage include
assessing: capillary refill; skin color, temperature, and turgor; level of
consciousness; neck veins; and mucous membranes. However, another
action is the nurse's priority.
C. It is important for the nurse to insert an indwelling urinary catheter to
assess the client for hypovolemia. The most objective assessment of
oxygenation and organ perfusion is urinary output of at least 30 ml/hr.
However, another action is the nurse's priority.
D. It is important for the nurse to prepare the client for a blood
transfusion to replace the amount of blood lost from postpartum
hemorrhage. It is crucial to restore circulating blood volume. However,
another action is the nurse's priority.
◉ A nurse is caring for a client who is to receive oxytocin to augment
her labor. Which of the following findings contraindicates the initiation
of the oxytocin infusion and should be reported to the provider?
,A. Late decelerations
B. Moderate variability of the FHR
C. Cessation of uterine dilation
D. Prolonged active phase of labor. Answer: A. Late declarations
- Late decelerations are indicative of uteroplacental insufficiency.
Therefore, this is a contraindication for the administration of oxytocin
and should be reported to the provider.
Rationale:
B. Moderate variability of the FHR is an expected assessment finding
associated with normal fetal acid-base balance. It is not a
contraindication to the administration of oxytocin.
C. Cessation of uterine dilation is an indication for the initiation of an
oxytocin infusion to augment the client's labor progression.
D. A prolonged active phase of labor is an indication for the initiation of
an oxytocin infusion to augment the client's labor progression.
, ◉ A nurse is assessing a client who has severe preeclampsia. Which of
the following manifestations should the nurse expect?
A. 2+ deep tendon reflexes
B. Proteinuria of 200 mg in a 24-hr specimen
C. Polyuria
D. Blurred vision. Answer: D. Blurred vision
- The nurse should identify that a client who has severe preeclampsia can
have arteriolar vasospasms and decreased blood flow to the retina which
can lead to visual disturbances, such as blurred vision, double vision, or
dark spots in the visual field.
Rationale:
A. The nurse should identify that a client who has severe preeclampsia
can have hyperactive reflexes of 3+ or 4+. Deep tendon reflexes of 2+ is
indicative of an active or expected response.
