NURS230 Maternal-Newborn Nursing Exam Prep – Real Practice Questions,
Answers & Detailed Rationales (Updated 2026) | Prenatal Care &
Pregnancy Changes, Labor & Delivery Nursing, Fetal Heart Rate Monitoring, High-
Risk Obstetric Conditions, Postpartum Care & Recovery, Newborn Assessment &
Neonatal Safety, Breastfeeding Support, Maternal-Newborn Pharmacology &
NCLEX-Style Clinical Judgment
Question 1: A nurse is assessing a pregnant client at 28 weeks gestation. Which
finding should the nurse report immediately to the healthcare provider?
A. Mild ankle edema that resolves with elevation
B. Blood pressure of 138/88 mm Hg on two separate readings
C. Weight gain of 1 pound per week
D. Occasional Braxton Hicks contractions
CORRECT ANSWER: B. Blood pressure of 138/88 mm Hg on two separate readings
Rationale: A blood pressure of 138/88 mm Hg on two separate readings meets criteria
for gestational hypertension (systolic ≥140 or diastolic ≥90 mm Hg). While 138/88 is
borderline, consistent readings at or above this threshold require immediate evaluation
for preeclampsia. Mild edema, appropriate weight gain, and Braxton Hicks contractions
are expected findings in the third trimester and do not require urgent reporting.
Question 2: During a prenatal visit, a client at 12 weeks gestation asks about the
purpose of folic acid supplementation. Which response by the nurse is most
accurate?
A. "Folic acid prevents gestational diabetes."
B. "Folic acid reduces the risk of neural tube defects in the developing fetus."
C. "Folic acid helps control morning sickness."
D. "Folic acid strengthens maternal bone density."
CORRECT ANSWER: B. "Folic acid reduces the risk of neural tube defects in the
developing fetus."
Rationale: Folic acid supplementation (400-800 mcg daily) before conception and
during early pregnancy is critical for preventing neural tube defects such as spina bifida
and anencephaly. It does not prevent gestational diabetes, control nausea, or directly
affect maternal bone density.
Question 3: A nurse is teaching a pregnant client about danger signs during
pregnancy. Which symptom should the client be instructed to report immediately?
A. Increased vaginal discharge
B. Swelling of the face and hands
C. Mild lower back pain
D. Frequent urination
CORRECT ANSWER: B. Swelling of the face and hands
,Rationale: Sudden or severe swelling of the face and hands is a warning sign of
preeclampsia and requires immediate medical evaluation. Increased vaginal discharge,
mild back pain, and frequent urination are common, expected findings during
pregnancy and typically do not indicate complications.
Question 4: A client at 36 weeks gestation presents with painless, bright red vaginal
bleeding. The nurse suspects which condition?
A. Placental abruption
B. Placenta previa
C. Preterm labor
D. Cervical polyp
CORRECT ANSWER: B. Placenta previa
Rationale: Painless, bright red vaginal bleeding in the third trimester is classic for
placenta previa, where the placenta partially or completely covers the cervical os.
Placental abruption typically presents with painful bleeding and uterine tenderness.
Preterm labor involves regular contractions with cervical change, and cervical polyps
usually cause minimal spotting.
Question 5: Which assessment finding in a newborn at 1 hour of life requires
immediate nursing intervention?
A. Acrocyanosis
B. Heart rate of 110 beats per minute
C. Respiratory rate of 68 breaths per minute with grunting
D. Temperature of 97.8°F (36.6°C)
CORRECT ANSWER: C. Respiratory rate of 68 breaths per minute with grunting
Rationale: Grunting is a sign of respiratory distress in newborns, indicating attempts to
maintain functional residual capacity. A respiratory rate >60 breaths per minute with
grunting requires immediate assessment and intervention. Acrocyanosis is normal in
the first 24-48 hours, a heart rate of 110 bpm is within normal limits (110-160 bpm), and
97.8°F is an acceptable temperature for a newborn.
Question 6: A nurse is caring for a postpartum client who is 24 hours after a vaginal
delivery. Which finding indicates the need for further assessment?
A. Fundus firm at the umbilicus
B. Lochia rubra with small clots
C. Perineal pain rated 3/10
D. Temperature of 100.4°F (38°C)
CORRECT ANSWER: D. Temperature of 100.4°F (38°C)
Rationale: A temperature of 100.4°F (38°C) or higher after the first 24 hours postpartum
may indicate infection (e.g., endometritis, urinary tract infection) and requires further
assessment. In the first 24 hours, mild temperature elevation can occur due to
,dehydration, but persistent fever warrants investigation. A firm fundus at the umbilicus,
lochia rubra with small clots, and mild perineal pain are expected findings.
Question 7: When teaching a new mother about newborn feeding cues, which
behavior should the nurse identify as an early sign of hunger?
A. Crying vigorously
B. Turning head side to side with mouth open (rooting)
C. Falling asleep at the breast
D. Pushing the breast away
CORRECT ANSWER: B. Turning head side to side with mouth open (rooting)
Rationale: Rooting is an early hunger cue in newborns. Crying is a late sign of hunger
and can make latching more difficult. Falling asleep or pushing the breast away
indicates satiety, not hunger. Teaching parents to recognize early cues promotes
successful breastfeeding.
Question 8: A client with gestational diabetes is being discharged. Which
statement by the client indicates understanding of self-care management?
A. "I will check my blood glucose only in the morning."
B. "I can skip my insulin if I feel well."
C. "I will eat three large meals and avoid snacks."
D. "I will monitor my blood glucose before meals and at bedtime as prescribed."
CORRECT ANSWER: D. "I will monitor my blood glucose before meals and at
bedtime as prescribed."
Rationale: Consistent blood glucose monitoring per prescription (typically fasting and
postprandial) is essential for managing gestational diabetes. Checking only once daily,
skipping insulin, or eating infrequent large meals can lead to poor glycemic control and
fetal complications.
Question 9: During the fourth stage of labor, which nursing action is the priority?
A. Assisting the mother with her first shower
B. Assessing uterine tone and lochia every 15 minutes
C. Providing perineal ice packs
D. Documenting the birth details
CORRECT ANSWER: B. Assessing uterine tone and lochia every 15 minutes
Rationale: The fourth stage of labor (immediate postpartum) carries the highest risk for
postpartum hemorrhage. Frequent assessment of uterine tone (firmness) and lochia
(amount, color) is critical to detect and intervene early for hemorrhage. Other
interventions are important but secondary to hemorrhage prevention.
Question 10: A nurse is preparing to administer Rho(D) immune globulin to a
postpartum client. Which assessment is essential before administration?
, A. Maternal blood type and Rh status
B. Newborn's Apgar scores
C. Maternal rubella immunity status
D. Timing of last tetanus vaccination
CORRECT ANSWER: A. Maternal blood type and Rh status
Rationale: Rho(D) immune globulin is indicated for Rh-negative mothers who deliver an
Rh-positive infant to prevent isoimmunization. Confirming maternal Rh-negative status
and infant Rh-positive status is essential before administration. Apgar scores, rubella
status, and tetanus vaccination are unrelated to RhoGAM indication.
Question 11: Which finding in a 2-day-old newborn is consistent with physiologic
jaundice?
A. Jaundice appearing within the first 24 hours of life
B. Total bilirubin of 18 mg/dL at 48 hours
C. Jaundice that starts on the face and progresses caudally
D. Direct (conjugated) bilirubin elevation
CORRECT ANSWER: C. Jaundice that starts on the face and progresses caudally
Rationale: Physiologic jaundice typically appears after 24 hours, peaks at 3-5 days, and
follows a cephalocaudal pattern (face to trunk to extremities). Jaundice within 24 hours
suggests pathologic causes. A bilirubin of 18 mg/dL at 48 hours may require
phototherapy depending on the infant's age in hours and risk factors. Elevated direct
bilirubin indicates liver pathology, not physiologic jaundice.
Question 12: A pregnant client at 10 weeks gestation reports severe nausea and
vomiting. Which intervention should the nurse recommend first?
A. Prescribe antiemetic medication
B. Advise eating dry crackers before rising in the morning
C. Schedule intravenous fluid therapy
D. Recommend complete bed rest
CORRECT ANSWER: B. Advise eating dry crackers before rising in the morning
Rationale: Non-pharmacologic interventions like eating dry carbohydrates before
getting out of bed are first-line for managing nausea in early pregnancy. Medications and
IV fluids are reserved for hyperemesis gravidarum unresponsive to conservative
measures. Bed rest is not indicated and may worsen symptoms.
Question 13: During a newborn assessment, the nurse notes a soft, swelling mass
on the infant's scalp that crosses suture lines. How should the nurse document this
finding?
A. Cephalohematoma
B. Caput succedaneum
Answers & Detailed Rationales (Updated 2026) | Prenatal Care &
Pregnancy Changes, Labor & Delivery Nursing, Fetal Heart Rate Monitoring, High-
Risk Obstetric Conditions, Postpartum Care & Recovery, Newborn Assessment &
Neonatal Safety, Breastfeeding Support, Maternal-Newborn Pharmacology &
NCLEX-Style Clinical Judgment
Question 1: A nurse is assessing a pregnant client at 28 weeks gestation. Which
finding should the nurse report immediately to the healthcare provider?
A. Mild ankle edema that resolves with elevation
B. Blood pressure of 138/88 mm Hg on two separate readings
C. Weight gain of 1 pound per week
D. Occasional Braxton Hicks contractions
CORRECT ANSWER: B. Blood pressure of 138/88 mm Hg on two separate readings
Rationale: A blood pressure of 138/88 mm Hg on two separate readings meets criteria
for gestational hypertension (systolic ≥140 or diastolic ≥90 mm Hg). While 138/88 is
borderline, consistent readings at or above this threshold require immediate evaluation
for preeclampsia. Mild edema, appropriate weight gain, and Braxton Hicks contractions
are expected findings in the third trimester and do not require urgent reporting.
Question 2: During a prenatal visit, a client at 12 weeks gestation asks about the
purpose of folic acid supplementation. Which response by the nurse is most
accurate?
A. "Folic acid prevents gestational diabetes."
B. "Folic acid reduces the risk of neural tube defects in the developing fetus."
C. "Folic acid helps control morning sickness."
D. "Folic acid strengthens maternal bone density."
CORRECT ANSWER: B. "Folic acid reduces the risk of neural tube defects in the
developing fetus."
Rationale: Folic acid supplementation (400-800 mcg daily) before conception and
during early pregnancy is critical for preventing neural tube defects such as spina bifida
and anencephaly. It does not prevent gestational diabetes, control nausea, or directly
affect maternal bone density.
Question 3: A nurse is teaching a pregnant client about danger signs during
pregnancy. Which symptom should the client be instructed to report immediately?
A. Increased vaginal discharge
B. Swelling of the face and hands
C. Mild lower back pain
D. Frequent urination
CORRECT ANSWER: B. Swelling of the face and hands
,Rationale: Sudden or severe swelling of the face and hands is a warning sign of
preeclampsia and requires immediate medical evaluation. Increased vaginal discharge,
mild back pain, and frequent urination are common, expected findings during
pregnancy and typically do not indicate complications.
Question 4: A client at 36 weeks gestation presents with painless, bright red vaginal
bleeding. The nurse suspects which condition?
A. Placental abruption
B. Placenta previa
C. Preterm labor
D. Cervical polyp
CORRECT ANSWER: B. Placenta previa
Rationale: Painless, bright red vaginal bleeding in the third trimester is classic for
placenta previa, where the placenta partially or completely covers the cervical os.
Placental abruption typically presents with painful bleeding and uterine tenderness.
Preterm labor involves regular contractions with cervical change, and cervical polyps
usually cause minimal spotting.
Question 5: Which assessment finding in a newborn at 1 hour of life requires
immediate nursing intervention?
A. Acrocyanosis
B. Heart rate of 110 beats per minute
C. Respiratory rate of 68 breaths per minute with grunting
D. Temperature of 97.8°F (36.6°C)
CORRECT ANSWER: C. Respiratory rate of 68 breaths per minute with grunting
Rationale: Grunting is a sign of respiratory distress in newborns, indicating attempts to
maintain functional residual capacity. A respiratory rate >60 breaths per minute with
grunting requires immediate assessment and intervention. Acrocyanosis is normal in
the first 24-48 hours, a heart rate of 110 bpm is within normal limits (110-160 bpm), and
97.8°F is an acceptable temperature for a newborn.
Question 6: A nurse is caring for a postpartum client who is 24 hours after a vaginal
delivery. Which finding indicates the need for further assessment?
A. Fundus firm at the umbilicus
B. Lochia rubra with small clots
C. Perineal pain rated 3/10
D. Temperature of 100.4°F (38°C)
CORRECT ANSWER: D. Temperature of 100.4°F (38°C)
Rationale: A temperature of 100.4°F (38°C) or higher after the first 24 hours postpartum
may indicate infection (e.g., endometritis, urinary tract infection) and requires further
assessment. In the first 24 hours, mild temperature elevation can occur due to
,dehydration, but persistent fever warrants investigation. A firm fundus at the umbilicus,
lochia rubra with small clots, and mild perineal pain are expected findings.
Question 7: When teaching a new mother about newborn feeding cues, which
behavior should the nurse identify as an early sign of hunger?
A. Crying vigorously
B. Turning head side to side with mouth open (rooting)
C. Falling asleep at the breast
D. Pushing the breast away
CORRECT ANSWER: B. Turning head side to side with mouth open (rooting)
Rationale: Rooting is an early hunger cue in newborns. Crying is a late sign of hunger
and can make latching more difficult. Falling asleep or pushing the breast away
indicates satiety, not hunger. Teaching parents to recognize early cues promotes
successful breastfeeding.
Question 8: A client with gestational diabetes is being discharged. Which
statement by the client indicates understanding of self-care management?
A. "I will check my blood glucose only in the morning."
B. "I can skip my insulin if I feel well."
C. "I will eat three large meals and avoid snacks."
D. "I will monitor my blood glucose before meals and at bedtime as prescribed."
CORRECT ANSWER: D. "I will monitor my blood glucose before meals and at
bedtime as prescribed."
Rationale: Consistent blood glucose monitoring per prescription (typically fasting and
postprandial) is essential for managing gestational diabetes. Checking only once daily,
skipping insulin, or eating infrequent large meals can lead to poor glycemic control and
fetal complications.
Question 9: During the fourth stage of labor, which nursing action is the priority?
A. Assisting the mother with her first shower
B. Assessing uterine tone and lochia every 15 minutes
C. Providing perineal ice packs
D. Documenting the birth details
CORRECT ANSWER: B. Assessing uterine tone and lochia every 15 minutes
Rationale: The fourth stage of labor (immediate postpartum) carries the highest risk for
postpartum hemorrhage. Frequent assessment of uterine tone (firmness) and lochia
(amount, color) is critical to detect and intervene early for hemorrhage. Other
interventions are important but secondary to hemorrhage prevention.
Question 10: A nurse is preparing to administer Rho(D) immune globulin to a
postpartum client. Which assessment is essential before administration?
, A. Maternal blood type and Rh status
B. Newborn's Apgar scores
C. Maternal rubella immunity status
D. Timing of last tetanus vaccination
CORRECT ANSWER: A. Maternal blood type and Rh status
Rationale: Rho(D) immune globulin is indicated for Rh-negative mothers who deliver an
Rh-positive infant to prevent isoimmunization. Confirming maternal Rh-negative status
and infant Rh-positive status is essential before administration. Apgar scores, rubella
status, and tetanus vaccination are unrelated to RhoGAM indication.
Question 11: Which finding in a 2-day-old newborn is consistent with physiologic
jaundice?
A. Jaundice appearing within the first 24 hours of life
B. Total bilirubin of 18 mg/dL at 48 hours
C. Jaundice that starts on the face and progresses caudally
D. Direct (conjugated) bilirubin elevation
CORRECT ANSWER: C. Jaundice that starts on the face and progresses caudally
Rationale: Physiologic jaundice typically appears after 24 hours, peaks at 3-5 days, and
follows a cephalocaudal pattern (face to trunk to extremities). Jaundice within 24 hours
suggests pathologic causes. A bilirubin of 18 mg/dL at 48 hours may require
phototherapy depending on the infant's age in hours and risk factors. Elevated direct
bilirubin indicates liver pathology, not physiologic jaundice.
Question 12: A pregnant client at 10 weeks gestation reports severe nausea and
vomiting. Which intervention should the nurse recommend first?
A. Prescribe antiemetic medication
B. Advise eating dry crackers before rising in the morning
C. Schedule intravenous fluid therapy
D. Recommend complete bed rest
CORRECT ANSWER: B. Advise eating dry crackers before rising in the morning
Rationale: Non-pharmacologic interventions like eating dry carbohydrates before
getting out of bed are first-line for managing nausea in early pregnancy. Medications and
IV fluids are reserved for hyperemesis gravidarum unresponsive to conservative
measures. Bed rest is not indicated and may worsen symptoms.
Question 13: During a newborn assessment, the nurse notes a soft, swelling mass
on the infant's scalp that crosses suture lines. How should the nurse document this
finding?
A. Cephalohematoma
B. Caput succedaneum
