Maternal Newborn Final Exam Study Questions,
Elaborate and Detailed answers
A nurse is caring for a client who is 8 hours postpartum and is experiencing hemorrhage. Which
of the following actions should the nurse implement after notifying the provider? (Select all that
apply)
A. Massage the fundus.
B. Give oxygen at 2L/min via nasal cannula.
C. Administer oxytocin.
D. Insert an indwelling catheter.
E. Place the client in a lateral position with her legs elevated 30 degrees. - Correct Answers A, C,
D, E
While assessing a client in the fourth stage of labor, the nurse suspects bladder distention. Which
of the following findings would the nurse expect to see?
A. The fundus is displaced from the midline.
B. The uterus is firm.
C. The fundus is below the umbilicus.
D. The bladder is resonant with percussion. - Correct Answers A
A nurse is testing the reflexes of a newborn to assess neurological maturity. Which of the
following reflexes is the nurse assessing by holding the newborn upright with feet touching a flat
surface?
A. Babinski Reflex
,B. Moro Reflex
C. Stepping Reflex
D. Plantar Grasp Reflex - Correct Answers C
The nurse in the newborn nursery has just received report. Which of the following infants should
the nurse see FIRST?
A. A 2 day old infant who is lying quietly alert with a heart rate of 185
B. A 1 day old infant who is crying and has a bulging anterior fontanel
C. A 12 hour old infant who is being held, with respirations that are 45 breaths per minute and
regular
D.A 5 hour old infant who is sleeping and whose hands and feet are blue bilaterally - Correct
Answers A
The nurse on a postpartum unit is preparing 4 clients for discharge. It would be MOST important
for the nurse to refer which of the following clients for home care?
A. A 15 year old primipara who delivered a 7 lb male 2 days ago
B. An 18 year old multipara who delivered a 9 lb female by c-section 2 days ago
C. A 20 year old multipara who delivered 1 day ago and is complaining of cramping
D. A 22 year old who delivered by c-section and is complaining of burning on urination - Correct
Answers D
The nurse teaches a primigravid woman how to measure the frequency of uterine contractions.
The nurse should explain to the client that the frequency of uterine contractions is determined by
which of the following?
A. By timing from the beginning of one contraction to the end of the next contraction
B. By timing from the beginning of one contraction to the end of the same contraction
C. By the number of contractions that occur within a given period of time
D. By the strength of the contraction at its peak - Correct Answers C
, Which of the following are presumptive signs of pregnancy? (Select all that apply)
A. Positive pregnancy test
B. Enlarged breasts
C. Urinary frequency
d. Braxton Hicks contractions
E. Fetal heart tones heard by the provider
F. Amenorrhea - Correct Answers B, C, F
Which of the following is the priority during the third stage of labor for the mother?
A. Educating the mother
B. Pain management
C. Skin to skin contact
D. Adequate tissue perfusion - Correct Answers D
Which fetal presentation is optimal for vaginal delivery?
A. Military
B. Brow
C. Vertex
D. Face - Correct Answers C
A woman in labor starts to exhibit late decels on the EFM, what actions should the nurse take?
Select all that apply
A. Give 02
B. Turn patient on left side
C. Put patient in Trendelenburg position
D. Decrease IV fluids
E. Raise the pt.s feet above the level of her heart - Correct Answers A, B
Elaborate and Detailed answers
A nurse is caring for a client who is 8 hours postpartum and is experiencing hemorrhage. Which
of the following actions should the nurse implement after notifying the provider? (Select all that
apply)
A. Massage the fundus.
B. Give oxygen at 2L/min via nasal cannula.
C. Administer oxytocin.
D. Insert an indwelling catheter.
E. Place the client in a lateral position with her legs elevated 30 degrees. - Correct Answers A, C,
D, E
While assessing a client in the fourth stage of labor, the nurse suspects bladder distention. Which
of the following findings would the nurse expect to see?
A. The fundus is displaced from the midline.
B. The uterus is firm.
C. The fundus is below the umbilicus.
D. The bladder is resonant with percussion. - Correct Answers A
A nurse is testing the reflexes of a newborn to assess neurological maturity. Which of the
following reflexes is the nurse assessing by holding the newborn upright with feet touching a flat
surface?
A. Babinski Reflex
,B. Moro Reflex
C. Stepping Reflex
D. Plantar Grasp Reflex - Correct Answers C
The nurse in the newborn nursery has just received report. Which of the following infants should
the nurse see FIRST?
A. A 2 day old infant who is lying quietly alert with a heart rate of 185
B. A 1 day old infant who is crying and has a bulging anterior fontanel
C. A 12 hour old infant who is being held, with respirations that are 45 breaths per minute and
regular
D.A 5 hour old infant who is sleeping and whose hands and feet are blue bilaterally - Correct
Answers A
The nurse on a postpartum unit is preparing 4 clients for discharge. It would be MOST important
for the nurse to refer which of the following clients for home care?
A. A 15 year old primipara who delivered a 7 lb male 2 days ago
B. An 18 year old multipara who delivered a 9 lb female by c-section 2 days ago
C. A 20 year old multipara who delivered 1 day ago and is complaining of cramping
D. A 22 year old who delivered by c-section and is complaining of burning on urination - Correct
Answers D
The nurse teaches a primigravid woman how to measure the frequency of uterine contractions.
The nurse should explain to the client that the frequency of uterine contractions is determined by
which of the following?
A. By timing from the beginning of one contraction to the end of the next contraction
B. By timing from the beginning of one contraction to the end of the same contraction
C. By the number of contractions that occur within a given period of time
D. By the strength of the contraction at its peak - Correct Answers C
, Which of the following are presumptive signs of pregnancy? (Select all that apply)
A. Positive pregnancy test
B. Enlarged breasts
C. Urinary frequency
d. Braxton Hicks contractions
E. Fetal heart tones heard by the provider
F. Amenorrhea - Correct Answers B, C, F
Which of the following is the priority during the third stage of labor for the mother?
A. Educating the mother
B. Pain management
C. Skin to skin contact
D. Adequate tissue perfusion - Correct Answers D
Which fetal presentation is optimal for vaginal delivery?
A. Military
B. Brow
C. Vertex
D. Face - Correct Answers C
A woman in labor starts to exhibit late decels on the EFM, what actions should the nurse take?
Select all that apply
A. Give 02
B. Turn patient on left side
C. Put patient in Trendelenburg position
D. Decrease IV fluids
E. Raise the pt.s feet above the level of her heart - Correct Answers A, B
