NURS230 Maternal-Newborn Nursing Exam Prep – Real Practice Questions,
Answers & Detailed Rationales (Updated 2026) | Prenatal Care & Fetal
Development, High-Risk Pregnancy Conditions, Labor & Delivery Nursing Care,
Fetal Heart Monitoring, Obstetric Emergencies, Postpartum Recovery, Newborn
Assessment & Safety, Breastfeeding Support, Maternal-Newborn Pharmacology &
NCLEX-Style Clinical Scenarios
Question 1: A nurse is assessing a pregnant client at 28 weeks gestation. Which
finding should the nurse report to the healthcare provider immediately?
A. Mild ankle edema that resolves with elevation
B. Blood pressure of 138/88 mmHg on two consecutive readings
C. Weight gain of 1 pound per week
D. Occasional Braxton Hicks contractions
CORRECT ANSWER: B. Blood pressure of 138/88 mmHg on two consecutive
readings
Rationale: A blood pressure reading of 138/88 mmHg on two consecutive occasions in a
pregnant client at 28 weeks gestation may indicate gestational hypertension or
preeclampsia, which requires immediate evaluation. While mild edema, appropriate
weight gain, and Braxton Hicks contractions are common and expected findings in
pregnancy, elevated blood pressure is a critical sign that warrants prompt intervention
to prevent maternal and fetal complications.
Question 2: During the fourth stage of labor, which assessment finding is the
priority for the nurse to evaluate?
A. Fundal firmness and location
B. Perineal edema and bruising
C. Maternal report of hunger
D. Newborn's Apgar score at 5 minutes
CORRECT ANSWER: A. Fundal firmness and location
Rationale: During the fourth stage of labor (immediate postpartum period), the priority
nursing assessment is fundal firmness and location to detect uterine atony, which is the
leading cause of postpartum hemorrhage. A boggy or displaced fundus requires
immediate intervention such as fundal massage to prevent excessive blood loss. While
perineal assessment, maternal comfort, and newborn status are important,
hemodynamic stability takes precedence.
Question 3: A newborn is assessed 1 hour after birth. Which finding requires
immediate nursing intervention?
A. Acrocyanosis of hands and feet
B. Respiratory rate of 58 breaths per minute
C. Central cyanosis of the lips and tongue
D. Heart rate of 145 beats per minute
CORRECT ANSWER: C. Central cyanosis of the lips and tongue
,Rationale: Central cyanosis (bluish discoloration of the lips, tongue, and trunk) in a
newborn indicates inadequate oxygenation and requires immediate assessment and
intervention, such as clearing the airway, providing oxygen, or initiating resuscitation
protocols. Acrocyanosis (peripheral cyanosis) is normal in the first 24-48 hours. A
respiratory rate of 58 and heart rate of 145 are within normal newborn ranges.
Question 4: A client at 36 weeks gestation reports sudden, painless, bright red
vaginal bleeding. The nurse recognizes this as a classic sign of which condition?
A. Placenta previa
B. Placental abruption
C. Preterm labor
D. Cervical insufficiency
CORRECT ANSWER: A. Placenta previa
Rationale: Painless, bright red vaginal bleeding in the third trimester is the hallmark sign
of placenta previa, where the placenta partially or completely covers the cervical os.
Placental abruption typically presents with painful, dark red bleeding and uterine
tenderness. Preterm labor involves regular contractions with cervical change, and
cervical insufficiency usually presents with painless cervical dilation without bleeding.
Question 5: Which nursing intervention is most appropriate for a client
experiencing hyperemesis gravidarum?
A. Encourage large, frequent meals to maintain nutrition
B. Administer antiemetic medications as prescribed before meals
C. Restrict oral fluids to prevent vomiting episodes
D. Advise the client to avoid all carbohydrates
CORRECT ANSWER: B. Administer antiemetic medications as prescribed before
meals
Rationale: Hyperemesis gravidarum involves severe nausea and vomiting leading to
dehydration and electrolyte imbalances. Administering antiemetics before meals helps
control symptoms and promotes oral intake. Small, frequent bland meals are preferred
over large meals. Fluid restriction is contraindicated as hydration is critical.
Carbohydrates are not universally restricted; individual tolerance guides dietary
planning.
Question 6: A nurse is teaching a postpartum client about lochia. Which statement
by the client indicates understanding?
A. "Lochia should become heavier and brighter red after the first week."
B. "I should report foul-smelling lochia or large clots to my provider."
C. "Lochia alba typically lasts for the first 3-4 days after birth."
D. "It is normal for lochia to stop completely by day 5 postpartum."
,CORRECT ANSWER: B. "I should report foul-smelling lochia or large clots to my
provider."
Rationale: Foul-smelling lochia may indicate infection, and large clots may suggest
retained placental fragments or uterine atony, both requiring medical evaluation. Lochia
typically progresses from rubra (days 1-3) to serosa (days 4-10) to alba (days 11-21+),
becoming lighter in color and amount over time. Lochia should not become heavier
after the first week, and it does not typically stop completely by day 5.
Question 7: When performing Leopold maneuvers on a client at 38 weeks gestation,
the nurse palpates a firm, round, movable part in the fundus and a soft, irregular
part just above the symphysis pubis. What fetal presentation does this indicate?
A. Vertex presentation
B. Breech presentation
C. Transverse lie
D. Shoulder presentation
CORRECT ANSWER: B. Breech presentation
Rationale: In Leopold maneuvers, a firm, round, movable part in the fundus is the fetal
head, while a soft, irregular part above the symphysis is the buttocks, indicating a
breech presentation. In vertex presentation, the head would be in the lower uterine
segment. Transverse lie presents with the fetal spine palpable horizontally, and
shoulder presentation is a type of transverse lie.
Question 8: A newborn is scheduled to receive vitamin K injection. The parent asks
why this is necessary. What is the nurse's best response?
A. "Vitamin K helps prevent bleeding disorders because newborns have low levels at
birth."
B. "Vitamin K boosts the newborn's immune system against infections."
C. "Vitamin K is required to help the newborn digest breast milk properly."
D. "Vitamin K prevents jaundice in the first week of life."
CORRECT ANSWER: A. "Vitamin K helps prevent bleeding disorders because
newborns have low levels at birth."
Rationale: Newborns are born with physiologically low levels of vitamin K, which is
essential for synthesis of clotting factors II, VII, IX, and X. Administering vitamin K
prophylactically prevents vitamin K deficiency bleeding (VKDB), a potentially life-
threatening condition. Vitamin K does not boost immunity, aid digestion, or prevent
jaundice.
Question 9: A client with preeclampsia is receiving magnesium sulfate. Which
assessment finding indicates magnesium toxicity?
A. Deep tendon reflexes of 2+
B. Respiratory rate of 16 breaths per minute
, C. Urine output of 40 mL/hr
D. Absent patellar reflexes
CORRECT ANSWER: D. Absent patellar reflexes
Rationale: Magnesium sulfate is a central nervous system depressant used to prevent
seizures in preeclampsia. Signs of toxicity include loss of deep tendon reflexes (first
sign), respiratory depression (<12 breaths/min), and decreased urine output (<30
mL/hr). Absent patellar reflexes require immediate intervention, including stopping the
infusion and administering calcium gluconate as an antidote.
Question 10: Which finding in a postpartum client on day 2 requires immediate
nursing action?
A. Temperature of 100.4°F (38°C)
B. Complaints of afterpains during breastfeeding
C. Saturation of one peripad in 30 minutes with bright red blood
D. Mild perineal discomfort rated 3/10
CORRECT ANSWER: C. Saturation of one peripad in 30 minutes with bright red
blood
Rationale: Saturating a peripad in 30 minutes with bright red blood indicates excessive
postpartum bleeding and possible hemorrhage, requiring immediate assessment of
fundal tone, massage if boggy, and notification of the provider. A temperature of 100.4°F
in the first 24 hours may be due to dehydration; afterpains and mild discomfort are
expected postpartum findings.
Question 11: A nurse is caring for a client in active labor. The fetal monitor shows
late decelerations. What is the nurse's priority action?
A. Increase the oxytocin infusion rate
B. Reposition the client to left lateral position
C. Prepare for immediate cesarean birth
D. Administer an opioid analgesic for pain
CORRECT ANSWER: B. Reposition the client to left lateral position
Rationale: Late decelerations indicate uteroplacental insufficiency and fetal hypoxia.
The priority nursing intervention is to improve placental perfusion by repositioning the
mother to left lateral position, administering oxygen, increasing IV fluids, and
discontinuing oxytocin if infusing. Immediate cesarean may be needed if interventions
fail, but repositioning is the first action.
Question 12: Which statement by a pregnant client indicates a need for further
teaching about nutrition?
A. "I should increase my folic acid intake to prevent neural tube defects."
B. "I can continue to eat deli meats as long as I heat them until steaming."
Answers & Detailed Rationales (Updated 2026) | Prenatal Care & Fetal
Development, High-Risk Pregnancy Conditions, Labor & Delivery Nursing Care,
Fetal Heart Monitoring, Obstetric Emergencies, Postpartum Recovery, Newborn
Assessment & Safety, Breastfeeding Support, Maternal-Newborn Pharmacology &
NCLEX-Style Clinical Scenarios
Question 1: A nurse is assessing a pregnant client at 28 weeks gestation. Which
finding should the nurse report to the healthcare provider immediately?
A. Mild ankle edema that resolves with elevation
B. Blood pressure of 138/88 mmHg on two consecutive readings
C. Weight gain of 1 pound per week
D. Occasional Braxton Hicks contractions
CORRECT ANSWER: B. Blood pressure of 138/88 mmHg on two consecutive
readings
Rationale: A blood pressure reading of 138/88 mmHg on two consecutive occasions in a
pregnant client at 28 weeks gestation may indicate gestational hypertension or
preeclampsia, which requires immediate evaluation. While mild edema, appropriate
weight gain, and Braxton Hicks contractions are common and expected findings in
pregnancy, elevated blood pressure is a critical sign that warrants prompt intervention
to prevent maternal and fetal complications.
Question 2: During the fourth stage of labor, which assessment finding is the
priority for the nurse to evaluate?
A. Fundal firmness and location
B. Perineal edema and bruising
C. Maternal report of hunger
D. Newborn's Apgar score at 5 minutes
CORRECT ANSWER: A. Fundal firmness and location
Rationale: During the fourth stage of labor (immediate postpartum period), the priority
nursing assessment is fundal firmness and location to detect uterine atony, which is the
leading cause of postpartum hemorrhage. A boggy or displaced fundus requires
immediate intervention such as fundal massage to prevent excessive blood loss. While
perineal assessment, maternal comfort, and newborn status are important,
hemodynamic stability takes precedence.
Question 3: A newborn is assessed 1 hour after birth. Which finding requires
immediate nursing intervention?
A. Acrocyanosis of hands and feet
B. Respiratory rate of 58 breaths per minute
C. Central cyanosis of the lips and tongue
D. Heart rate of 145 beats per minute
CORRECT ANSWER: C. Central cyanosis of the lips and tongue
,Rationale: Central cyanosis (bluish discoloration of the lips, tongue, and trunk) in a
newborn indicates inadequate oxygenation and requires immediate assessment and
intervention, such as clearing the airway, providing oxygen, or initiating resuscitation
protocols. Acrocyanosis (peripheral cyanosis) is normal in the first 24-48 hours. A
respiratory rate of 58 and heart rate of 145 are within normal newborn ranges.
Question 4: A client at 36 weeks gestation reports sudden, painless, bright red
vaginal bleeding. The nurse recognizes this as a classic sign of which condition?
A. Placenta previa
B. Placental abruption
C. Preterm labor
D. Cervical insufficiency
CORRECT ANSWER: A. Placenta previa
Rationale: Painless, bright red vaginal bleeding in the third trimester is the hallmark sign
of placenta previa, where the placenta partially or completely covers the cervical os.
Placental abruption typically presents with painful, dark red bleeding and uterine
tenderness. Preterm labor involves regular contractions with cervical change, and
cervical insufficiency usually presents with painless cervical dilation without bleeding.
Question 5: Which nursing intervention is most appropriate for a client
experiencing hyperemesis gravidarum?
A. Encourage large, frequent meals to maintain nutrition
B. Administer antiemetic medications as prescribed before meals
C. Restrict oral fluids to prevent vomiting episodes
D. Advise the client to avoid all carbohydrates
CORRECT ANSWER: B. Administer antiemetic medications as prescribed before
meals
Rationale: Hyperemesis gravidarum involves severe nausea and vomiting leading to
dehydration and electrolyte imbalances. Administering antiemetics before meals helps
control symptoms and promotes oral intake. Small, frequent bland meals are preferred
over large meals. Fluid restriction is contraindicated as hydration is critical.
Carbohydrates are not universally restricted; individual tolerance guides dietary
planning.
Question 6: A nurse is teaching a postpartum client about lochia. Which statement
by the client indicates understanding?
A. "Lochia should become heavier and brighter red after the first week."
B. "I should report foul-smelling lochia or large clots to my provider."
C. "Lochia alba typically lasts for the first 3-4 days after birth."
D. "It is normal for lochia to stop completely by day 5 postpartum."
,CORRECT ANSWER: B. "I should report foul-smelling lochia or large clots to my
provider."
Rationale: Foul-smelling lochia may indicate infection, and large clots may suggest
retained placental fragments or uterine atony, both requiring medical evaluation. Lochia
typically progresses from rubra (days 1-3) to serosa (days 4-10) to alba (days 11-21+),
becoming lighter in color and amount over time. Lochia should not become heavier
after the first week, and it does not typically stop completely by day 5.
Question 7: When performing Leopold maneuvers on a client at 38 weeks gestation,
the nurse palpates a firm, round, movable part in the fundus and a soft, irregular
part just above the symphysis pubis. What fetal presentation does this indicate?
A. Vertex presentation
B. Breech presentation
C. Transverse lie
D. Shoulder presentation
CORRECT ANSWER: B. Breech presentation
Rationale: In Leopold maneuvers, a firm, round, movable part in the fundus is the fetal
head, while a soft, irregular part above the symphysis is the buttocks, indicating a
breech presentation. In vertex presentation, the head would be in the lower uterine
segment. Transverse lie presents with the fetal spine palpable horizontally, and
shoulder presentation is a type of transverse lie.
Question 8: A newborn is scheduled to receive vitamin K injection. The parent asks
why this is necessary. What is the nurse's best response?
A. "Vitamin K helps prevent bleeding disorders because newborns have low levels at
birth."
B. "Vitamin K boosts the newborn's immune system against infections."
C. "Vitamin K is required to help the newborn digest breast milk properly."
D. "Vitamin K prevents jaundice in the first week of life."
CORRECT ANSWER: A. "Vitamin K helps prevent bleeding disorders because
newborns have low levels at birth."
Rationale: Newborns are born with physiologically low levels of vitamin K, which is
essential for synthesis of clotting factors II, VII, IX, and X. Administering vitamin K
prophylactically prevents vitamin K deficiency bleeding (VKDB), a potentially life-
threatening condition. Vitamin K does not boost immunity, aid digestion, or prevent
jaundice.
Question 9: A client with preeclampsia is receiving magnesium sulfate. Which
assessment finding indicates magnesium toxicity?
A. Deep tendon reflexes of 2+
B. Respiratory rate of 16 breaths per minute
, C. Urine output of 40 mL/hr
D. Absent patellar reflexes
CORRECT ANSWER: D. Absent patellar reflexes
Rationale: Magnesium sulfate is a central nervous system depressant used to prevent
seizures in preeclampsia. Signs of toxicity include loss of deep tendon reflexes (first
sign), respiratory depression (<12 breaths/min), and decreased urine output (<30
mL/hr). Absent patellar reflexes require immediate intervention, including stopping the
infusion and administering calcium gluconate as an antidote.
Question 10: Which finding in a postpartum client on day 2 requires immediate
nursing action?
A. Temperature of 100.4°F (38°C)
B. Complaints of afterpains during breastfeeding
C. Saturation of one peripad in 30 minutes with bright red blood
D. Mild perineal discomfort rated 3/10
CORRECT ANSWER: C. Saturation of one peripad in 30 minutes with bright red
blood
Rationale: Saturating a peripad in 30 minutes with bright red blood indicates excessive
postpartum bleeding and possible hemorrhage, requiring immediate assessment of
fundal tone, massage if boggy, and notification of the provider. A temperature of 100.4°F
in the first 24 hours may be due to dehydration; afterpains and mild discomfort are
expected postpartum findings.
Question 11: A nurse is caring for a client in active labor. The fetal monitor shows
late decelerations. What is the nurse's priority action?
A. Increase the oxytocin infusion rate
B. Reposition the client to left lateral position
C. Prepare for immediate cesarean birth
D. Administer an opioid analgesic for pain
CORRECT ANSWER: B. Reposition the client to left lateral position
Rationale: Late decelerations indicate uteroplacental insufficiency and fetal hypoxia.
The priority nursing intervention is to improve placental perfusion by repositioning the
mother to left lateral position, administering oxygen, increasing IV fluids, and
discontinuing oxytocin if infusing. Immediate cesarean may be needed if interventions
fail, but repositioning is the first action.
Question 12: Which statement by a pregnant client indicates a need for further
teaching about nutrition?
A. "I should increase my folic acid intake to prevent neural tube defects."
B. "I can continue to eat deli meats as long as I heat them until steaming."
